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413
Perspective .
.
.‘.
Desperately Linda
Seeking
Reimbursement
Dickes1
A patient disturbances
with lung cancer who was experiencing visual and severe headaches underwent CT of the
tween lung cancer and a procedure for examining the head. If the claim had been submitted with diagnostic codes for the
billed, and nonradiology personnel are not educated as to the technology provided. The tendency is to assume that reimbursement is almost routine, but in fact, considerable effort is required to obtain payments for radiologic procedures. Insurers have a variety of claims-review mechanisms to limit payments to care that appears necessary for beneficiaries and that meets the policy’s requirements. Medicaid programs in most states and health maintenance organizations
neurologic
(HMOs)
head to evaluate
the possibility
of metastases.
Reimburse-
ment for the CT scan was denied initially by the patient’s insurance company because the company’s computerized claims-review program could not discern a relationship be-
symptoms,
then the relationship
between
the pro-
cedure and the patient’s medical problem would have been clear. In fact, when the claim was recorded and resubmitted, the procedure In another
tered
was reimbursed. instance, a hospital’s
separate
billing
radiology
charges
department
for the volume
en-
of nonionic
contrast medium used for each enhanced procedure. The hospital’s billing staff, who in the past had not billed separately for contrast media, simply transferred the charges to an inventory control account rather than adding a line item to the claim. As a consequence, the hospital lost revenue for a
covered
service until a reimbursement
specialist
maceutical company identified the problem seminar for the hospital’s radiology, billing,
ords
departments
on insurer
policies
from a phar-
and organized a and medical rec-
and
required
billing
information.
Common
Reimbursement
Problems
Both of these situations ment
problems:
the patient’s
claim
condition,
data
exhibit
three common
do not relate
services
covered
reimburse-
the examination
by insurance
to
are not
Radiologists
Bristol Myers Squibb Co., Pharmaceutical
AJR 159:413-414,
August
1992 0361-803X/92/1
Group, P. 0. Box 4000, Princeton, 592-0413
© American Roentgen
requirements
to limit the use of
as Consultants
As noted in a text on quality assurance for radiology departments, “the radiologist’s role as a consultant and gatekeeper is critical, avoiding unnecessary and inappropriate tests and directing the rest of the medical staff’s access to imaging sources” [1 1. As other physicians may be unfamiliar with today’s high-technology imaging capabilities, diagnostic specialists must serve as consultants to their referral network. The primary care physician should be educated regarding the type
of information
diagnostic
Received April 22, 1991 ; accepted after revision February 24, 1992. Presented in whole or in part at the Economics of Diagnostic Imaging National Symposium, Administrators, and the meeting of the Califomia Society of Radiology Technologists. This work was supported by Squibb Diagnostics, a division of Bristol-Myers Squibb Co. 1
use prior-approval
diagnostic and other health care services. Medicare and most commercial insurers may deny reimbursement if the services provided are not deemed medically necessary. It is the radiologist, not the primary care physician, who risks not being paid when the service provided is not justified or supported by the claim data. If you cannot answer the question “For what medical reason is this diagnostisc procedure necessary?” you probably will not be paid.
NJ 08543-4000. Ray Society
physician
the National
Address
about
patients
can select
Convention
reprint
requests
that
is needed
the technology
of the American
to Public
Affairs
Health
Dept.
so that
the
that
is most
Care
Radiology
414
DICKES
appropriate referring
in making
physician
Downloaded from www.ajronline.org by 117.253.226.218 on 11/03/15 from IP address 117.253.226.218. Copyright ARRS. For personal use only; all rights reserved
may be better
a differentiating
may be familiar
for imaging
diagnosis.
with CT scans,
the patient’s
Although
a
MR imaging
medical
performed
reimbursement can be effectively munication produces a “win-win”
will be related.
Ensuring
only for procedures The 1 988 Medicare
that Car-
rier Manual [2], published by the American Medical Association, describes a medically necessary procedure as one that is or diagnoses
safely
can
to the patient.
Such regulations are not unique in the payers’ demand for justification of health care expenditures. Virtually every insurance policy contains some type of clause on medical necessity. They are intended primarily to exclude payment for
noncovered
services,
such as cosmetic
surgery.
However,
they also provide claims reviewers with a mechanism to deny reimbursement for procedures that seem unreasonable, unrelated, or unnecessary with respect to a patient’s current health problems. Consequently, it is important for a radiologist’s report to include information on why the patient was
referred cause
for the procedure, of the
patient’s
additional
medical
reimbursement and information
history,
services and
required results
contrast
professional
this information
media as “constandards.”
extends
be-
of the
The
beyond
of an individual claim. The more clinical on utilization patterns that are submitted
each claim and the more claims submitted
the data with
for reimbursement
for use of nonionic contrast media, the stronger pattern of use of nonionic media, which creates for the establishment of future reimbursement
but also influence
convenience of the or another physician
level which
accepted
of submitting
becomes the a foundation based on fee
can not centers
and national reimbursement policies. recently in a Medicare jurisdiction that had a policy of not providing reimbursement for the additional costs involved in using nonionic contrast media. An imaging center in the jurisdiction resubmitted 1 00 claims on which the charges for nonionic contrast media had been denied. Included with the resubmitted claims were dictated reports explaining the medical necessity for using nonionic contrast media and clinical studies supporting the decision to use such media. At a subsequent meeting with the Medicare hearing officer, a radiologist from the imaging center explained the differences between ionic and nonionic contrast agents, identified medical necessity factors, and described the clinical
An example
and effectively
the use of nonionic
generally
schedules. By taking an active role as consultants, radiologists only enhance reimbursement rates for their medical
of the
generally accepted (i.e., not experimen-
or supplier; and Furnished at the most appropriate be provided
with
usefulness
Consistent with the symptoms illness or injury under treatment; Necessary and consistent with professional medical standards tal or investigational); Not furnished primarily for the patient, the attending physician,
Such clear com-
Reimbursement
have established
Necessity
Third-party payers will reimburse are defined as medically necessary.
1992
Clinical data from journals and health care practitioners and information on utilization patterns of diagnostic procedures sistent
Medical
processed. scenario.
August
problem.
Therefore, while the purpose of the examination is set by the patient’s physician, the type of examination should be selected by the diagnostic specialist. This is the best way to ensure that the medical necessity for the examination and the
procedure
AJA:159,
state
of this occurred
basis for using nonionic
media.
The radiologist
also catego-
nzed patient factors that could be used to classify the various claims according to procedure performed and nonionic contrast agent used. As a result of this effort, 90% of the previously denied
claims
were
reimbursed
immediately.
The hearing
officer’s
examination that will affect the plan of treatment. These data are later coded on a claim form by billing personnel. The coded information must paint a picture of a health care expense that is clinically necessary in order for the provider to be reimbursed for the services.
findings were summarized for the specific claims reviewed and to establish a general application. It was decided that irrespective of general policy, services deemed reasonable and necessary could be reimbursed on a case-by-case basis. Thus, a precedent was set for processing future claims for reimbursement for the use of nonionic contrast media.
Value
This example shows that process that can be influenced
of Communication
The efforts of referring physicians and radiologists working together are a prerequisite for reimbursement, but their working together does not guarantee it. Accurate and comprehensive coding of the dictated report and effective communication between radiologists and their hospitals’ billing departments
also are necessary. Exchange
of detailed
medical
histories
benefits
reimbursement through better
is a dynamic
documentation and communication. Radiologists can perform a key role in the team effort to obtain appropriate reimbursement levels by educating referral sources, medical staff, claims reviewers, and policy makers. The net result for radiologists will be
increasing radiologic
acceptance technology
of nonionic
contrast
and even greater
media and other
professional
stature.
everyone.
The radiologist is able to select the most effective imaging technique for the examination. The referring physician receives diagnostic data specific to his patient’s acute problem, which confirms his medical suspicions or redirects the plan of treatment. The third-party payer can then receive claim data indicating the medical necessity of the examination so that
REFERENCES 1 . Handmaker
H, Sawyer evaluation in diagnostic cine services. Chicago: Organizations, 1988:9 2. Medicare carrier review.
TG, Wilkinson A. Examples of monitoring and radiology, radiation oncology, and nuclear mediJoint Commission on Accreditation of Healthcare Chicago:
American
Medical
Association,
1988:12
413
Perspective .
.
.‘.
Desperately Linda
Seeking
Reimbursement
Dickes1
A patient disturbances
with lung cancer who was experiencing visual and severe headaches underwent CT of the
tween lung cancer and a procedure for examining the head. If the claim had been submitted with diagnostic codes for the
billed, and nonradiology personnel are not educated as to the technology provided. The tendency is to assume that reimbursement is almost routine, but in fact, considerable effort is required to obtain payments for radiologic procedures. Insurers have a variety of claims-review mechanisms to limit payments to care that appears necessary for beneficiaries and that meets the policy’s requirements. Medicaid programs in most states and health maintenance organizations
neurologic
(HMOs)
head to evaluate
the possibility
of metastases.
Reimburse-
ment for the CT scan was denied initially by the patient’s insurance company because the company’s computerized claims-review program could not discern a relationship be-
symptoms,
then the relationship
between
the pro-
cedure and the patient’s medical problem would have been clear. In fact, when the claim was recorded and resubmitted, the procedure In another
tered
was reimbursed. instance, a hospital’s
separate
billing
radiology
charges
department
for the volume
en-
of nonionic
contrast medium used for each enhanced procedure. The hospital’s billing staff, who in the past had not billed separately for contrast media, simply transferred the charges to an inventory control account rather than adding a line item to the claim. As a consequence, the hospital lost revenue for a
covered
service until a reimbursement
specialist
maceutical company identified the problem seminar for the hospital’s radiology, billing,
ords
departments
on insurer
policies
from a phar-
and organized a and medical rec-
and
required
billing
information.
Common
Reimbursement
Problems
Both of these situations ment
problems:
the patient’s
claim
condition,
data
exhibit
three common
do not relate
services
covered
reimburse-
the examination
by insurance
to
are not
Radiologists
Bristol Myers Squibb Co., Pharmaceutical
AJR 159:413-414,
August
1992 0361-803X/92/1
Group, P. 0. Box 4000, Princeton, 592-0413
© American Roentgen
requirements
to limit the use of
as Consultants
As noted in a text on quality assurance for radiology departments, “the radiologist’s role as a consultant and gatekeeper is critical, avoiding unnecessary and inappropriate tests and directing the rest of the medical staff’s access to imaging sources” [1 1. As other physicians may be unfamiliar with today’s high-technology imaging capabilities, diagnostic specialists must serve as consultants to their referral network. The primary care physician should be educated regarding the type
of information
diagnostic
Received April 22, 1991 ; accepted after revision February 24, 1992. Presented in whole or in part at the Economics of Diagnostic Imaging National Symposium, Administrators, and the meeting of the Califomia Society of Radiology Technologists. This work was supported by Squibb Diagnostics, a division of Bristol-Myers Squibb Co. 1
use prior-approval
diagnostic and other health care services. Medicare and most commercial insurers may deny reimbursement if the services provided are not deemed medically necessary. It is the radiologist, not the primary care physician, who risks not being paid when the service provided is not justified or supported by the claim data. If you cannot answer the question “For what medical reason is this diagnostisc procedure necessary?” you probably will not be paid.
NJ 08543-4000. Ray Society
physician
the National
Address
about
patients
can select
Convention
reprint
requests
that
is needed
the technology
of the American
to Public
Affairs
Health
Dept.
so that
the
that
is most
Care
Radiology
414
DICKES
appropriate referring
in making
physician
Downloaded from www.ajronline.org by 117.253.226.218 on 11/03/15 from IP address 117.253.226.218. Copyright ARRS. For personal use only; all rights reserved
may be better
a differentiating
may be familiar
for imaging
diagnosis.
with CT scans,
the patient’s
Although
a
MR imaging
medical
performed
reimbursement can be effectively munication produces a “win-win”
will be related.
Ensuring
only for procedures The 1 988 Medicare
that Car-
rier Manual [2], published by the American Medical Association, describes a medically necessary procedure as one that is or diagnoses
safely
can
to the patient.
Such regulations are not unique in the payers’ demand for justification of health care expenditures. Virtually every insurance policy contains some type of clause on medical necessity. They are intended primarily to exclude payment for
noncovered
services,
such as cosmetic
surgery.
However,
they also provide claims reviewers with a mechanism to deny reimbursement for procedures that seem unreasonable, unrelated, or unnecessary with respect to a patient’s current health problems. Consequently, it is important for a radiologist’s report to include information on why the patient was
referred cause
for the procedure, of the
patient’s
additional
medical
reimbursement and information
history,
services and
required results
contrast
professional
this information
media as “constandards.”
extends
be-
of the
The
beyond
of an individual claim. The more clinical on utilization patterns that are submitted
each claim and the more claims submitted
the data with
for reimbursement
for use of nonionic contrast media, the stronger pattern of use of nonionic media, which creates for the establishment of future reimbursement
but also influence
convenience of the or another physician
level which
accepted
of submitting
becomes the a foundation based on fee
can not centers
and national reimbursement policies. recently in a Medicare jurisdiction that had a policy of not providing reimbursement for the additional costs involved in using nonionic contrast media. An imaging center in the jurisdiction resubmitted 1 00 claims on which the charges for nonionic contrast media had been denied. Included with the resubmitted claims were dictated reports explaining the medical necessity for using nonionic contrast media and clinical studies supporting the decision to use such media. At a subsequent meeting with the Medicare hearing officer, a radiologist from the imaging center explained the differences between ionic and nonionic contrast agents, identified medical necessity factors, and described the clinical
An example
and effectively
the use of nonionic
generally
schedules. By taking an active role as consultants, radiologists only enhance reimbursement rates for their medical
of the
generally accepted (i.e., not experimen-
or supplier; and Furnished at the most appropriate be provided
with
usefulness
Consistent with the symptoms illness or injury under treatment; Necessary and consistent with professional medical standards tal or investigational); Not furnished primarily for the patient, the attending physician,
Such clear com-
Reimbursement
have established
Necessity
Third-party payers will reimburse are defined as medically necessary.
1992
Clinical data from journals and health care practitioners and information on utilization patterns of diagnostic procedures sistent
Medical
processed. scenario.
August
problem.
Therefore, while the purpose of the examination is set by the patient’s physician, the type of examination should be selected by the diagnostic specialist. This is the best way to ensure that the medical necessity for the examination and the
procedure
AJA:159,
state
of this occurred
basis for using nonionic
media.
The radiologist
also catego-
nzed patient factors that could be used to classify the various claims according to procedure performed and nonionic contrast agent used. As a result of this effort, 90% of the previously denied
claims
were
reimbursed
immediately.
The hearing
officer’s
examination that will affect the plan of treatment. These data are later coded on a claim form by billing personnel. The coded information must paint a picture of a health care expense that is clinically necessary in order for the provider to be reimbursed for the services.
findings were summarized for the specific claims reviewed and to establish a general application. It was decided that irrespective of general policy, services deemed reasonable and necessary could be reimbursed on a case-by-case basis. Thus, a precedent was set for processing future claims for reimbursement for the use of nonionic contrast media.
Value
This example shows that process that can be influenced
of Communication
The efforts of referring physicians and radiologists working together are a prerequisite for reimbursement, but their working together does not guarantee it. Accurate and comprehensive coding of the dictated report and effective communication between radiologists and their hospitals’ billing departments
also are necessary. Exchange
of detailed
medical
histories
benefits
reimbursement through better
is a dynamic
documentation and communication. Radiologists can perform a key role in the team effort to obtain appropriate reimbursement levels by educating referral sources, medical staff, claims reviewers, and policy makers. The net result for radiologists will be
increasing radiologic
acceptance technology
of nonionic
contrast
and even greater
media and other
professional
stature.
everyone.
The radiologist is able to select the most effective imaging technique for the examination. The referring physician receives diagnostic data specific to his patient’s acute problem, which confirms his medical suspicions or redirects the plan of treatment. The third-party payer can then receive claim data indicating the medical necessity of the examination so that
REFERENCES 1 . Handmaker
H, Sawyer evaluation in diagnostic cine services. Chicago: Organizations, 1988:9 2. Medicare carrier review.
TG, Wilkinson A. Examples of monitoring and radiology, radiation oncology, and nuclear mediJoint Commission on Accreditation of Healthcare Chicago:
American
Medical
Association,
1988:12
