MRI Survey Results

Because many of our Neurosurgery clients are introducing MRI services into their practice offerings, KZA thought the survey recently conducted with Orthopaedic peers might be of interest. Important findings include difficulty in some regions obtaining necessary credentialing status as well as increased pre-authorization requirements. Both issues result in increased staff time and effort which can drive up the overhead. While MRI services can be financially successful, physicians are encouraged to thoroughly research their marketplace and understand potential barriers. For more details, read the survey write up below:

A total of 154 responses were received from Orthopaedic practices across the country including:

Fully 83% (128 of 154) responded that the insurance plans with which they participate require pre-certification of MRIs. This extra step of either calling, faxing, or in some cases submitting information online requires time and attention of clinical or clerical staff that typically have additional duties. KZA asked specifically which plans require pre-certification and the top five plans, besides Workers Compensation, included:

• Blue Cross Blue Shield plans including various state plans, Anthem, Empire, Highmark, Capital, Horizon, Wellmark, Blue Choice, PPO, etc.

• Cigna

• Aetna

• United Healthcare

• Tricare

Interestingly, several respondents noted that "all" or "most all" of their plans require pre-certification; one respondent clarified "some – but the trend is more rather than less." This statement summarizes the movement within the industry – MRI pre-certification is a growing trend, not one that is going away.

Practices are advised to survey major plans annually regarding pre-certification requirements for any ancillary service offerings and ensure procedures are in place to accommodate this requirement.

The survey also asked if plans required the practice to undergo separate credentialing (in addition to the physician credentialing typically required for plan participation) for MRI services in order to be paid. 14% (22 of 154) answered yes; additional credentialing was required, while 51% (78 of 154) answered no. An additional 35% of respondents were unsure if additional credentialing requirements existed for MRI services. For those practices indicating additional credentialing was required, overwhelmingly the specific plans cited were BCBS and related plans. Cigna, Humana, Oxford and Aetna also were listed. Of particular interest were those responses indicating various plans restricted the type of patients – practices were only allowed to provide imaging services for internal patients; no external referrals were allowed and paid. It is critical that practices considering adding MRI services contact major plans and fully understand credentialing requirements, network availability and any patient restrictions that may exist. Obviously these factors could significantly impact revenue and break-even projections.

Lastly, KZA inquired whether respondents had experienced denials from plans for reading MRIs (professional component); some plans are moving to payment only for credentialed radiologists or only for groups who have a radiologist on staff. 17% indicated they have received denials, while 77% have not; an additional 6% was unsure if they had experienced denials for this particular reason. More disconcerting than the professional read denials, was the fact that just 13% were able to appeal the actions successfully; clearly back end efforts are largely unsuccessful.

Given the changing political landscape in some states, Orthopaedic surgeons need to stay up to date on local and plan regulations concerning imaging services. Visit www.aaos.org and contact your state orthopaedic society for details on advocacy efforts.

Receiving denials related to imagine services and unsure how to proceed? Hire the EOB experts at KZA to review denials and make suggestions on appeal strategies.

KZA consultants can help draft action-oriented appeal letters that get results and coach employees on processes that improve collections success. No travel required! You send the EOBs and we send a written action summary and schedule a conference call to discuss.

To get started, download and complete the Prospective Client Information Survey (PCIS) at and call Colleen Gallagher at (312) 642-5616 for additional information and pricing.