Technological Advances
in Radiology Billing:
We Can Automate That!

radiology biller with piles of papers, technology concept
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Technological Advances in Radiology Billing

We Can Automate That!

Pat Kroken, FACMPE, CRA, FRBMA
July/August 2021 RBMA Bulletin

Technological advances in radiology billing have lowered costs, increased productivity and successfully sped up cash flow.  I have managed offices in both the old world of legacy technology and in the new world of real-time, high-powered information management.  The new world is better but it can also lead to dangerous assumptions and unrealistic expectations.  More on that in a minute.

Hospital Downloads

Take hospital downloads.  When I first started in radiology, the group received a daily download of all hospital patients’ demographics, whether or not they had radiology procedures. 

There was a separate file of radiology reports, which were printed and manually sorted alphabetically.  A data entry clerk then entered radiology report information that matched key data elements in the demographic file to create a record for that patient visit.  The patient could have multiple files and account numbers if, for example, one of the visits was for a workers’ compensation claim and/or he was a “frequent flier” for radiology services, visiting several sites of service. 

Enterprise accounts, with multiple insurance companies all under one account number, were still a distant dream.  There were no system checks to identify whether a claim was missing information or contained errors so an incomplete/incorrect record was often submitted, returned, corrected and re-submitted.  Foot-high stacks of paper were common even in a highly functional billing operation and stacks filled the desks and file cabinets of the billers.   

Financial Benefits of Automation

Radiology practices benefited financially from the impact of technology and automation, especially as the Health Insurance Portability and Accountability Act (HIPAA) mandated the use of standardized transactions and code sets so we could speak a common language.  Payment formats, status verifications and other key functions became consistent although it seemed insurance companies could still maneuver within the framework.    

At the same time billing system automation also improved front-end processes, including downloads that merged automatically to form patient accounts, software that identified missing and incorrect information (and forced correction before submission to insurance companies) which not only reduced the number of people required to process transactions but dramatically boosted cash flow with improved clean claims.

As a result, it took fewer employees to run a billing operation so costs declined for both inhouse departments and outsourced billing companies.  With persistent reductions in reimbursement over the years, increased automation better supported practice profitability.

“Just because you can automate something, it doesn’t mean you should.”

The Gap Between Expectations and Reality

We live in the promise of a better world through artificial intelligence (AI) and improvements in clinical performance are announced almost daily.  The world in a few years may look very different for radiologists that it currently does.  I will let the physician experts measure and comment on those developments.

However, on the billing and business side of radiology, promise is sometimes exceeding performance.  Technically a computer can be trained to perform a claims follow-up function but there is often a gap between expectations and reality.  It appears to be the result of a failure to understand operational workflow and complexities. 

For example, a hospital-based practice implemented technology that automatically rebilled insurance claims remaining unpaid after 30 days.  With most electronic payments occurring within 14 days, that could seem logical.  Since the computer could rebill the pending insurance claims, the vendor recommended having staff focus on denials rather than devoting time to insurance follow-up. 

Then the payment poster was out for two weeks.  Since insurance payments were not posted to the accounts, hundreds of them appeared to be unpaid and were automatically rebilled, triggering a rash of duplicate claim denials that began clogging the denials worklist.  Posting of “zero pay” transactions (denials) also piled up even after the payment poster returned, since she was trying to focus on clearing the payment backlog.  The ongoing bottleneck caused even more automatic filings and over the next few months, processes practically ground to a halt as automation continued to function as instructed.

The practice finally called for help and the first recommendation was, “Turn off the automatic rebill function.”  It took just over a year (yes, really) for the staff to clean up the wreckage and regain process control.

Billing Processes: A Lack of Understanding

There were several operational failures which appeared to result from a lack of understanding of billing processes.  They include:

  1. If a claim is unpaid after a definable period of time, there is a reason.
    If that reason is addressed, payment will usually follow but it takes action by a human.  The reason may be described in insurance correspondence (a soft denial), but the claim could also be caught in clearinghouse files or put on temporary hold in the insurance company’s portal.  Failure to prioritize correspondence or correct clearinghouse rejections will begin to cause backlogs, with the implications made even worse when they are allowed to sit untouched until timely filing limits are exceeded.  It happens.

  2. Failure to post payments.
    As payments are posted, a series of other actions are triggered, including submission of secondary insurance claims or patient statements.  And as noted in this illustration, if a paid claim is identified in the system as unpaid due to posting delays, automated actions can begin to pile up and clog the system.  A certain number of re-filed claims could also be incorrectly paid again, resulting in credit balances and refunds.  In a busy radiology practice, this will happen quickly. 

  3. Failure to post “zero pay” transactions.
    The payment poster is frequently the person to post “zero pay” transactions, which can appear intermingled with payments on many explanation of benefits reports but may also represent an entire EOB.  In the latter instance, these are apt to be set aside until payment backlogs are cleared.  When delayed, the system can again detect a balance on the account and rebill, triggering a duplicate claim denial.  Or when the zero pay transaction indicated another insurance company should be billed, delays in correcting information and resubmitting can result in a timely filing denial. 

Lessons Learned

Lessons learned?  Understand billing processes, including where human intervention and a judgment call are needed to keep things moving.  Make sure the staff keeps up with key processes—working insurance correspondence, the clearinghouse rejection file and zero pay transactions.  The practice discussed could have recovered more quickly if, when it was evident the payment poster would be out for more than a day, someone remembered to shut down the automation.  However, it’s too easy to forget what features were turned on and when.   

To further compound the problem with our practice in crisis, failure to receive a response from the insurance company also triggered an automatic transfer function that billed the next responsible party.  When there was no secondary insurance listed, the bill went to the patient.  For Medicare, Medicaid or workers’ compensation patients, this created a compliance problem.

Problems can also occur with the automation of denials, although the intelligent use of software solutions can facilitate efficiency by clearing out claims that would not be paid even upon appeal, based on prevailing medical policies.  An example would be an insurance company policy whereby only one procedure code is paid for a transabdominal/transvaginal ultrasound study and the other is denied.  The primary caution in this instance involves monitoring and understanding insurance company medical policies and ensuring the automated action does not occur for those companies that would pay for both procedures.  And checking activity over time since problems can surface with system updates or modifications that may impact programmed processes.

The Bottom Line

Bottom line, steps to automate billing processes should involve participation from operational staff who can identify potential problems stemming from process changes.  Radiology coding and billing is exceptionally complex, although workflow can be broken down into tidy process segments for process improvement purposes.  The staff is accustomed to dealing with medical policy inconsistencies, insurance plan idiosyncrasies and one-off process variations.  If their experience and participation is part of the automation strategy, there is a higher likelihood of success.  If not, the results can be painful.

With that said, the best way to ensure successful automation is to start with  highly functional and current baseline processes.  It isn’t fancy, but it is essential.  

Patricia Kroken, FACMPE, CRA, FRBMA,
has an extensive background in radiology practice management and directs education and corporate communications for MSN Healthcare Solutions

She worked as a consultant for radiology practices, billing companies, software developers, and hospital radiology departments for 20 years before joining MSN.

She is a regular contributor to the RBMA Bulletin and a frequent speaker on topics related to radiology practice management. 
Pat can be reached at pat.kroken@msnllc.com
or 505-856-6128

headshot of Pat Kroken Director of Education and Corporate communications, MSN Healthcare Solutions