Are Radiologists Responsible for Determining Medical Necessity?

Are Radiologists Responsible for Determining Medical Necessity?

Radiologists could be held responsible for providing evidence to support medical necessity for imaging tests and need to take measures to protect themselves.

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The growing volume of imaging tests and the number of procedures and medical diagnostic codes involved make radiology medical billing quite challenging. Radiologists may now be impacted by a legal decision that burdens them with the responsibility of ensuring proper clinical evidence to support medical necessity.

Medically necessary services or supplies are those that are needed for the diagnosis or treatment of a patient’s medical condition and meet accepted standards of medical practice.

Health insurance providers including Medicare provide coverage only for what they consider meets their requirements of medical necessity.

A recent case filed by an insurance company in New Jersey has put the spotlight on the radiologist’s role in determining medical necessity. The company’s lawyers argued that it is the radiologist’s responsibility to ensure that proper clinical evidence exists to support medical necessity and appropriateness. The plaintiff claimed that radiologists had conducted MRIs and X-rays on patients who had submitted personal injury claims without checking properly as to whether these studies were necessary. The company sued NJ radiologists to recover expenditures amounting to $200,000.

The radiologists argued that the referring physicians who send them patients are “verified” providers and meet the state’s requirements. However, the court ruled in favor of the payer, stating that the responsibility of ensuring that there is proper clinical evidence to support medical necessity and appropriateness lies with the radiologist.

Reporting on the New Jersey lawsuit in Diagnostic Imaging, an expert says that the New Jersey court decision is more likely to impact free-standing radiology imaging centers than hospital-based radiologists. The question being asked is: if radiologists are responsible for determining medical necessity, what can they do to protect themselves? The report offers the following suggestions: 

Ensure official documentation of medical necessity: Radiologists should work with their staff to collect as much clinical information as possible about patients.

They should adhere to the standard procedure to ensure official documentation of medical necessity by having patients fill out forms giving reasons for their clinical visit and request for a study.

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Collaborate openly with referring physicians: Checking up with the referring physician on each patient that arrives for an imaging test can be a daunting task for imaging centers. But if they have questions, they should contact the referring doctor and verify why the test was ordered. Interacting openly with the referring physicians on a daily basis is recommended as the latter will have all the information about the patient.

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Pay attention to patients with injury or workers’ compensation claims: Freestanding radiology imaging centers that have contracts with liability payers should pay special attention to determining medical necessity for patients with injury or workers’ compensation claims.

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Scrutinize payer contracts: These centers must scrutinize the payer contracts they sign to understand their responsibilities for determining medical necessity. They should examine the terms and conditions relating to injury or workers’ compensation categories.

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Know their own state rules: Radiologists should know their state rules and regulations to ensure compliance.

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Actively participate in forums and societies: They should actively participate in professional societies so that they can better voice their concerns in these public platforms.

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Organize records: Medical records should be maintained properly - this is a necessary defense in the case of audits.

Radiology practices are also at risk for claim denials due to patient eligibility problems and complex medical coding and billing requirements. These issues can be resolved by relying on professional support for patient eligibility verification and outsourced medical billing and coding services.

www.outsourcestrategies.com

Phone: 1-800-670-2809