Airtight contracts, timely response to denials can ease some claim payment pains

The relationship between radiologists and managed care plans is often subject to conflict over issues of payment, but a thorough understanding of contracts and timely, organized responses to problems that do arise can help guarantee correct claim payments, according to an article published in the June issue of the Journal of the American College of Radiology.

“All health care providers experience troubles when dealing with health plans, and radiologists and imaging centers are no exception,” wrote Robert Schiller, Esq., and Jacqueline Finnegan, Esq., from the Garfunkel Wild law firm in Great Neck, N.Y.

In fact, the troubles for radiologists regarding health plans have been increasing, noted the authors. Health plan denials for critical imaging services have doubled over the last four years, according to the Patient Advocate Foundation. For each denial, it takes professional case managers an average of 15.4 contacts (phone calls, emails, etc.) to determine the reason for denial and to resolve the conflict.

Schiller and Finnegan offered a number of suggestions for dealing with health plans and avoiding coverage denials, including:

• Have a well-drafted contract that addresses issues such as claims processing, coding, prior authorization and utilization review.
• Understand the health plan’s processes for referrals, prior authorization, payment bundling and appeals.
• Develop good working relationships with provider relations representatives from each health plan.
• Check the health plan’s provider file for the group and update the list of member physicians to avoid delays related to credentialing issues.

Should a claims problem still occur, radiology groups should thoroughly document all contact with the health plan and make a timely appeal, advised Schiller and Finnegan. If the health plan is not abiding by applicable law or terms of the provider agreement, submit a complaint to the appropriate regulatory body.

“Above all else, be vigilant. Generally, the longer you wait to raise an issue, the less likely you are to be fully compensated,” wrote the authors.