A Quick Introduction to Radiology Prior Authorization

One of the key factors for a successful reimbursement of the cost for a treatment by a payer is prior authorization. More often than not, failure to obtain prior authorization (or pre authorization, as it is sometimes called) for a medical procedure is the reason for denial by the insurance company to pay for the services rendered. And radiology is no different.

Radiology prior authorization is serious business. Some of the most common radiology exams that may require pre-authorization include

• CT scans
• MRI/MRA
• PET scans
• Stress Echo Cardiograms
• Bone Mineral Density exams, and more

Radiology prior authorization services can be a complex affair and they usually take days to be completed. Therefore, the process of authorization should ideally begin at the time a patient registers for an appointment. Information required to start the process include details about the patient’s condition and the reasons for the exam. In order to fill in the missing gaps in the information, personnel from the radiology department or imaging center may have to contact the referring physician’s office.

Once an exam is pre authorized by the insurance company, the radiology department must verify that the details of the exam authorized match those of the actual exam to be performed. It must also be remembered that the insurance company should be informed of any changes to the procedure actually ordered. This is necessary to ensure that the procedure codes mentioned on the final claim form match the payer’s authorization records.

Prior authorization is a process that seldom ends with just filing a request with the insurance company. Besides making sure that the request is free from errors, has the correct CPT or ICD codes and has all the required information, it also requires constant follow-ups by the radiology office. This is the biggest reason why radiology prior authorization services are often outsourced to dedicated third-party medical billers and coders. By doing so, one is more likely to see an improved efficiency in the manner prior auth requests are sent and in the rate of approvals. Needless to say, it also frees up the radiology staff to provide care to more patients.