Get it right the first time: 7 steps to clean claims

Desert Radiologists is a large radiology practice based in Las Vegas, Nevada. The group currently has 65 radiologists providing services in six practice-owned imaging centers as well as 24/7 professional services to 13 hospitals in Nevada, Texas and Oklahoma.  Here are our top seven tips for avoiding denied claims:

1. Eligibility pre-check.  The concept here is to engage a service to batch submit the upcoming schedules to check for insurance eligibility.  The key is to submit three to four days prior to the appointments to allow adequate time to address any discrepancies.  There are many companies that provide this service that are connected with insurance databases.  In the event that batch submission is not feasible, then resources should be dedicated to identify the patient’s eligibility prior to the day of the exam.  Desert Radiologists has implemented this process and makes sure to provide the co-pay and deductible information to the patient at the time they schedule their appointment.  Our patients really appreciate knowing in advance how much their expense is going to be.

1. Evaluation & Management documentation. It is very important to educate radiologists to include the time they spent with the patient in their dictation when performing any E & M service.  Many payors are denying this code due to the absence of the documented time.

1. Coding software tools that apply coding edits for the various payor contracts.  The various companies that provide this service stay current on the many coding edits that are implemented by payors.  It is important to develop a working relationship with the vendor to provide ongoing denials to them from the payors to reduce future denials.

1. Re-confirm at each visit the correct insurance for the patient.  We pay a lot of attention to confirming that visits are allocated to the right payor.  In the world of outpatient radiology, a patient will often have services due to workers’ compensation. A key to correct billing is to educate the registration staff how important it is to capture the correct insurance for the exam being provided.

1. 3D rendering documentation on CT angiography exams.  It is essential for the radiologist to include documentation that 3D rendering was performed in order to ensure appropriate reimbursement.  If the radiologist performs the 3D rendering at a different workstation, this also should be documented.

1. Continuous analysis of denials to identify areas to re-educate the registration staff.  In this area, Desert Radiologists has achieved significant success by reporting the results by staff member and tying staff members and supervisors to performance measures and annual performance evaluations.  In one year, we reduced the data-entry denials to less than 1% from an average of 3-4%.  With the volume that our practice has in outpatient registrations, the dollar value of this process has been significant.

1. Radiopharmaceutical invoices.  Our practice has identified that inclusion of the radiopharmaceutical invoice with the initial claim for nuclear studies results in improved claims processing on the first claim submission.

These are only a few of the processes that Desert Radiologists implements to ensure that claims are successfully processed and paid on the first submission. The key to successful clean claims processing and faster payment turnaround times is getting it right the first time.

Patricia A. Harms, MBA, CPA, FACMPE, is chief financial officer, Desert Radiologists, Las Vegas, Nev.