As the past few years have witnessed explosive growth in technology on the clinical side of radiology, the same trend has occurred in the “back office,” with advanced practice management systems that utilize technology to improve productivity, lower overhead, and increase revenue. Although a truly paperless office will probably never be achieved, the old days of manual processes, matching demographics with radiology reports, and digging through file folders to follow up on an insurance denial, have given way to new processes.

Data Acquisition

Data acquisition, the accumulation of information essential to filing a claim, was traditionally an area of inefficiency and paranoia. Hospital-based practices were frequently successful in electronically downloading demographic files; however, there was a cumbersome process involved in manually sorting radiology reports, usually by site and then in alphabetical order, to identify multiple procedures performed on the same day. The radiologist became justifiably paranoid, since it was difficult to ensure that all studies read had, in fact, been transferred to the billing office. Really, it was not a question of whether studies were missing, but how many. The problem was compounded by the fact that downloads often contained all patients admitted to the hospital, not just those who had been sent for a radiology procedure. Radiology reports were used to match certain criteria in order to pull patients out of the large file for billing. If the radiology report was not transferred, there was no mechanism to identify patients.

The new generation of practice management software has automated the matching process and can identify either missing reports or demographics. Omissions then appear in edit reports and allow for timely follow-up of missing procedures. In addition, the files can be computer-verified against a log sheet of scheduled examinations for further reassurance that all studies have been captured.

The software program reviews hospital files, selects those patients who meet certain criteria, and downloads only those patients into the system. Radiology reports are then brought in electronically and matched, or scanned and attached to the appropriate patients. If the system is set up on a one patient/one account system, all procedures are visible on the screen so that duplicate procedures on the same day can be identified easily. (Not all of the newer systems use the latter process for setting up patient accounts, so that represents a decision point for the practice. Neither methodology is wrong, but they represent different approaches in the management of information.)

The other exceptionally valuable electronic process involves a presubmission edit function. Claims are “scrubbed” to ensure that all required fields are filled, alphanumeric identifiers are complete, and, in the more sophisticated edit programs, coding is compared to Correct Coding Initiative (CCI) requirements or other coding criteria. There can be several defined edits within the entire presubmission process, improving the quality of clean claims submitted for payment and, therefore, improving cash flow. Although claims-editing functions have been available for a number of years, they have continued to improve, costs for the feature have declined, and they are now often offered in the core software system rather than as an add-on capability.


Coding productivity and accuracy also have improved through the use of technology. Automated coding utilizes intelligent software to read the radiology report and assign appropriate diagnosis (ICD-9) and procedure (CPT-4) codes. In some instances, the codes drop directly into the charge entry screen; in others, reports are flagged for review. This functionality has not eliminated the need for dedicated radiology coders, but has allowed practices and billing companies to reduce the size of the coding staff and reduce stress levels at the same time.

Facilitated coding also involves the elimination of tedious paper processes by scanning the report into the system, where it is presented on the screen along with demographics. Capabilities may include the ability to translate information from the hospital download, although coding accuracy varies with the quality of hospital data. The coder enters appropriate information in the charge entry screen and/or reviews the accuracy of transferred codes. Lookup functions assist with searches for specific codes, and internal edits minimize errors from transposition of numbers or the incorrect number of decimal places for ICD-9 codes.

Both options greatly increase staff productivity, especially since they automatically match demographic data and radiology reports, a tedious “before” process that often required considerable manual paper handling. Again, since documents are transferred into the system through scanning or electronically, the need for paper storage also is eliminated.

It should be noted that fully automated coding functions have been under review by the Office of Inspector General, although no adverse findings have been released at this time.

Document Management

Document management has evolved significantly from its early days of scanning static images into a file for retrieval, as, at that time, even being able to print a document from a scanned image was considered progress. However, those of us who struggled with the task of how to logically catalog, file, and retrieve explanation of benefits forms can attest to both the benefits and failures of initial forays into document scanning. In some cases, document management features may be available through vendor third-party relationships, where other programs integrate with the main practice management system, or are part of the core system.

Offering more than strictly storage and retrieval, however, the basis for advanced imaging technology embedded in today’s practice management systems lies in the acquisition of paper or electronic documents and the ability to search, retrieve, and store the images in an efficient manner. More importantly, however, is what can be done with information once acquired. “Smart” imaging technology can not only acquire documents but also read them, understand them, and process the information based on business intelligence—also allowing for correct routing, data entry, and decision-making. The new technology can attach radiology reports to a visit, a patient account, or an insurance payment and make it available on demand.

What does this mean in terms of efficiency? In most cases, the charge entry process can be automated, requiring a person to only work exceptions kicked out by an edit report.

Document management features are especially beneficial in terms of claims follow-up, since all pertinent activity is available by patient account. Rather than digging through file drawers (especially since things are often not where they should be), photocopying, and returning documents to files, the employee simply pulls up supporting documentation from records stored with the patient account. The process of filing secondary claims, workers’ compensation, and other situations requiring supporting documentation moves from minutes per transaction to seconds. Staff members also can pull necessary information from their desktop workstations, print, and go on to the next patient.

Billing and Collections

Billing and collections activities have traditionally involved management by rear-view mirror; that is, administrators reviewed retrospective reports of a month’s activity and, at best, were 30 days behind an operational problem. If charge entry, coding, or payment posting ran behind schedule, it could take weeks to quantify and rectify the problem. New technology allows for real-time viewing by person, so if charge entry is lagging behind schedule, it will be evident on the same day—as work is occurring—not when month-end reports are run.

Also, it traditionally was difficult to adequately monitor the productivity and workloads of staff members assigned to insurance follow-up. The latter department often is the most expensive part of the billing/collections process, so it is of concern in terms of efficiency. In pretechnology days, the prioritization of work for any given day relied on the good judgment of the person involved, with measurement of productivity usually based on monthly accounts receivable trends.

Advances in technology eliminate the reliance on good work habits in insurance follow-up and allow management to monitor progress daily. Now, systems can drop work into follow-up queues, which allow for sorting and prioritization by age of account, size of the patient’s balance, or denial reason. The various queues demand the entry of “action” dates and document work done on the account each day, so managers can review the status of activity—and the size of workloads—on a real-time basis. Since it is not unusual for external problems to inundate a particular staff member periodically, this monitoring also allows for workloads to be redistributed as necessary.

The insurance staff also can work many claims corrections on the Web, reducing the amount of staff time per patient account and concentrating telephone conversations on the exceptional, rather than routine, problems and corrections.

Denials Management

The effective denials management program seeks to correct the root cause of problems resulting in denials, in addition to streamlining the process of appealing claims. Denials management reporting has continued to improve as an analytical tool enabling the practice administrator to determine if problems are occurring during registration, as a result of coding documentation, or because of changes in payor rules.

Although denials management represents an evolving frontier for the radiology practice, the flexibility of management reporting has supported progress and improved cash flow for practices actively working in this area.


The implementation of advanced technology is redefining radiology performance benchmarks, and those achieving best-practices status are finding themselves in a highly evolutionary phase. Groups have begun to report staff reductions of up to 40%, lower overhead, improved collections, and reduced days in accounts receivable (days in A/R).

“The future holds dramatic improvements in the reduction of overhead and improved profitability, but at the price of accelerating rates of change.”
—Patricia Kroken, FACMPE, CRA

Vendors continue to focus their research and development efforts on improved features, so the rate of change should continue to accelerate. Companies are facing make-or-buy decisions regarding whether to partner with a third-party company or incorporate functionality into their core systems, and more of them seem to be choosing the latter. The market is highly competitive, and customers are actively seeking the improvements offered by new technology. Just as we have seen leaps in productivity for radiologists using picture archiving and communications systems (PACS), the business side of the practice is gaining significantly from technological advances as well.

As staff sizes are reduced, however, cross-training becomes more important. Since workloads in various areas can be monitored on a real-time basis, “float” positions can move between departments to where the work is, again allowing for proactive management on a real-time basis. For employees who grew up on dumb terminals, this method of working represents quantum change, with some employees proving to be highly adaptable and others, resistant. Traditional training needs to be revised for both management and staff to ensure that system capabilities are maximized.

In its earlier stages, technological advances were the realm of adventurous early adopters who worked through unanticipated issues and assisted vendors with product refinement. Over the past few years, the adoption of new technology, while still presenting challenges in terms of change management, has become more mainstream.

The future holds dramatic improvements in the reduction of overhead and improved profitability, but at the price of accelerating rates of change. Although stepping into the new world of radiology may be intimidating, the price of being left behind poses a much greater risk.

Patricia Kroken, FACMPE, CRA, is president of Healthcare Resource Providers, Albuquerque, NM.