Radiology Billing Denials from MRI Authorization Errors

MRI prior authorization helps payers to determine if a proposed imaging study meets the coverage needs. However, the examination done can differ from the original request because of several clinical findings, or recommendations made inside the imaging process. The claim can get denied even though the initial authorization was approved. Understanding who should verify, document and update the authorization is important for radiology centers to prevent reimbursement delays. This is where the requirement for outsourced radiology billing company comes into the picture.

Why MRI Protocols Change After Authorization?

A MRI request can be approved based on the information submitted by the payer. It includes the requested examinations and supporting details. If the planned services materially change, the original approval may not satisfy the payer needs. One common scenario incorporates contrast. A physician can request an MRI without contrast, but the imaging team can identify a concern that needs the radiologist to reassess the planned examination. Other changes involve performing examinations both before and after contrast, or selecting a different study based on the patient’s condition. For example, an MRI protocol may change from without contrast to with following clinical reassessment. If the provider doesn’t verify the revised services, a claim mismatch occurs.

How Can Authorized MRI Claims Get Denied?

Prior authorization indicates that a payer has approved a specified service under its applicable authorization rules. It doesn’t guarantee payment for each and every service performed because other claim requirements can still apply.

1) The Billed Service and Authorization Doesn’t Match

Authorization records can identify the procedure, contrast requirements, service location or other details payer use. If the final claim differs from the approved details, automatic edits can flag the claim. That is where clinics take the help of radiology billing services in that matter.

2 Incomplete Medical Necessity Documentation

Even if the original request is approved, proper documentation should support the completed examination. The Centers for Medicare and Medicaid Services explained that its applicable review programs evaluate the documentation process against Medicare needs. Prior authorization rules vary by payer, program, and service and clinics should not assume every MRI is subjected to the same authorization process.

3) The Provider Did Not Get Updated Authorization

When the planned examination change, staff should review the authorization terms to determine whether an amendment is required. It can leave the billing team unable to support the claim process if you fail to establish which of the requirements apply.

Who is Responsible for the Denial?

Responsibility depends on why the protocol changed, and the payer’s needs. An initial authorization approval doesn’t automatically make the ordering physician, or imaging facility mostly responsible for a denial.

1) The Ordering Physician

The physician is mostly responsible for communicating all the reasons for the examination and supplying records whenever needed. If a material change inside the intended study is important, the ordering office may provide updated clinical information depending on the insurer’s process.

2) The Radiologist and Imaging Center

The imaging facility should follow its operational and clinical protocols and determine whether they performed services stay within the authorization’s approved scope. Claim denials can be prevented with proper communication with the ordering physician. The reimbursement considerations should stay separate from clinical decisions. An imaging team should not perform a proper examination to match the authorization procedure.

3) The Billing and Authorization Team

The billing team needs to compare the authorization process with the final procedure code before the claim submission procedure. If the mismatch exists, staff needs to determine what amendments, or another payer-directed action is needed. The payer has a responsibility to communicate the applicable needs and explain denials according to the given rules. The American medical association has stated the significance of transparent authorization needs and detailed clinical explanations.

How Can Radiology Clinics Prevent MRI Authorization Denials?

Preventing all these denials need coordination amongst scheduling, staff, authorization and billing personnel. One of the effective approaches is to verify changes when they happen instead of discovering discrepancy after denying the payment procedure. The radiology billing outsourcing services know how to take the right steps to prevent denials.

1) Verifying the Authorization before the Scan