As time goes on, advancements in imaging are providing diagnostics that were literally unheard of even a decade ago. Doctors are better able to identify problems early enough to successfully treat a number of cancers and degenerative conditions that would have carried a death warrant just a few years ago because they would go undetected until late stages of the disease. Unfortunately, due to strict regulatory billing procedures, CMS (Centers for Medicare and Medicaid Services) rejects a high percentage of claims. Here are some of the top reasons why CMS refuses to pay for diagnostic imaging.
Does Not Meet ‘Medical Necessity’ Guidelines
In a document entitled Medicare Payments for Diagnostic Radiology Services in Emergency Departments, the Office of Inspector General (OIG) clearly states that radiology services must be ‘medically necessary.’ While this particular document is specific to emergency room treatments, the same principle holds true throughout all of Medicare and Medicaid guidelines.
Simply put, if the attending physician (provider) cannot substantiate that the imaging procedure was a medical necessity, chances are Medicare/Medicaid will refuse to pay the bill. Often times a physician ordering the test knows that it is a medical necessity to accurately make a diagnosis but is not able to communicate the need accurately on the invoice. Companies such as FRG are able to audit such invoices, find ways to substantiate the necessity of the imaging procedure and then help the physician recover the payment from Medicare that is ethically and legally owed to that provider.
Errors in Billing from Provider
As with anything else the government does, there is always more red tape than necessary when trying to get payment for services rendered. While medical billing is a highly specialized field of study and a profession that requires precision in coding, the government’s codes are not always in keeping with standardized codes within the industry. The billing clerk may erroneously code the imaging procedure based on how they would code a private insurance company but CMS, for some obscure reason, may code that same procedure by another name.
The actual radiology procedure may not be referred to in the same way, or for the same ultimate purpose, as in the private sector. This would cause CMS to summarily refuse to pay for that procedure. Even if it is one that meets the ‘medically necessary’ clause, if it is coded wrong it won’t get paid.
Frequency Limitations Exceeded
Then there is the frequency limitations clause. Some procedures are only allowed once in a 12 month period while others may be allowed once every two years, five years and so on. This can create a very real problem when the physician feels the first image wasn’t sufficient, perhaps because what he or she suspects to be the underlying problem was too early in the disease’s progression to be detected well on the image. It could also be that the radiologist was looking for something else and didn’t order a scan that would show on film what the physician was actually looking for. Getting CMS to pay for imaging repeated procedures can be a full time job and that’s why more and more doctors, clinics and hospitals are seeking professionals to help them recover payments which should have been made to them.
With government it is always black and white but FRG and other financial recovery groups are able to pull those ‘gray areas’ out of the proverbial hat in order to recover payments for their clients. CMS may not be willing to pay but there is usually a way to prove why they should. Don’t continue losing money with the false belief that there is no recourse. There is. It just might take a professional recovery group to get your payment but even so, help is out there so don’t despair.