You are the chief of a radiology group practice. A local physician in the area has a busy clinical practice and refers many patients to your radiology practice. In fact, this physician is one of your best referral sources. However, from your observations, you have noted that the physician has a tendency to order a higher proportion of imaging studies than most of the physician’s colleagues, with a much higher rate of requested MR imaging studies for certain “soft” indications (such as gadolinium-enhanced brain MR imaging for mild headaches).
In the past, your practice has received full payment of technical and professional fees from insurers for all of these studies, including imaging studies that were feared to be potentially “rejectable” by fastidious payers. Recently, you have been informed by several insurance companies in your area that they are hiring a new radiology benefits management firm, which is nationally known to be more stringent in recommending refusal of payment for imaging studies considered to be not clinically indicated.
Question 1 of 3: Which of the following would be the wisest course of action in the short term to optimize the flow of reimbursement payments for imaging studies to your practice?
Send one of your administrative staff to a coding and billing course so that he or she can keep you informed about what is going on in the reimbursement environment.
Inform the local physician about the changes in radiology reimbursement practices, and tell the physician that he or she needs to “shape up” or risk facing your wrath about ordering imaging studies that are refused payment by the insurers.
Review the previous month’s MR imaging orders, tally the potentially problematic cases, and arrange a discussion with the local physician about the upcoming changes and these potential “problem” cases.
Send notice to the insurers that you will take legal action if they refuse payment on any study that has already been accepted as necessary by your frontline staff.
Immediately install physician order entry systems on your practice Web site so that only appropriate imaging studies can be ordered and so inappropriate studies are automatically rejected.