Q&A: Dealing with the Impact of Radiology Benefit Managers

Diagnostic Imaging reached out to Taylor Moorehead, regional partner, West region at Zotec Partners, a medical billing, practice management, and Radiology Information Systems software company, to discuss the impact of Radiology Benefit Managers and technology aimed at helping practices deal with the demands.

First, can you describe the increasing demands of Radiology Benefit Management companies? What are radiology practices facing?

For radiology practices, it is an ongoing challenge to keep track of the volume of payer contracts and ensure that appropriate payment is received for contracted services. In addition,Radiology Benefit Management companies (RBMs) are becoming widely used by private payers to manage the utilization of imaging services through pre-authorization processes. As RBM involvement increases, so does the impact on volume, complexity, reduced reimbursement and cost to the practice due to the burden of pre-authorization.

There are a number of challenges the industry faces as a result of RBMs. During the recent RBMA conference, a panel comprised of the CEOs from five RBM companies conceded that roughly 20 to 40 percent of imaging studies are unnecessary, which is where they focus their attention and target their reductions. The CEOs also agreed that the most likely reduction in professional-fee reimbursement in the next five years will be 30 percent.

Radiology groups are now faced with determining what actions need to be taken to protect their businesses for the long term.

Can you give me an idea of how RBMs impact day-to-day practice operations? Where are they feeling the most pressure?

In this challenging environment, practice managers must be able to determine whether the practice is getting paid the right amount, quickly appeal short payments and denials, and follow up consistently to keep pressure on claim resolution. With legacy technology and unstructured processes, these tasks are labor intensive, subject to human oversight, and often result in lost revenue.

To address the increasing demands of RBMs, practice managers need to put systems in place to verify benefits, check for pre-authorizations or reauthorizations and stay aware of the proper CPT code for the exam being ordered. They can work to offset the impact of RBMs by optimizing and collecting every dollar from the payer and patient.

As payer contracting increasingly requires radiology groups to work with RBMs, expertise on payer trends, proper coding, and what exams are not considered medically necessary will be vital for ensuring radiologists are correctly reimbursed for their services.

In addition, a key component will be making effective use of technology that provides greater success in contract management and collecting from insurance companies.

What kinds of technology can be put in place to alleviate some of that burden? What are the benefits of using updated technology for these purposes?

Sophisticated decision support data mining and analysis tools provide the capability to measure the effectiveness of every letter, statement or phone call in any campaign - to show exactly how many dollars are being generated by each step in the billing process.

Technology, like decision support tools, provides greater success in contract management and collecting from insurance companies and plays a key role for radiology groups that are dealing with the RBMs. Decision support is essential for helping practices completely understand payment patterns and denial management. The software provides specific business intelligence to the group’s database, allowing it to effectively data mine, drill down, chart and analyze its data in a meaningful way.

Decision support technology should enable the group to automatically appeal denials for prompt turnaround, track payment variances from contracts, and provide comprehensive payer analysis.

Some of the robust billing systems store information concerning specific practice contract payment plans, including anticipated payments, per line item and per modifier. And the system automatically monitors whether practices are being paid the contracted amount. Exceptions are directed to an automated work file where they are reviewed and appealed electronically. The billing provider is able to demonstrate to the insurance carriers that the practice does not simply accept what they choose to pay, but has sophisticated tools to call them to account on each discrepancy, every time.