Although radiology practices contend with legislative changes, declining reimbursement rates, and much more, possibly the biggest hindrance to their success is radiology benefit management companies (RBMs). The RBMs are making it increasingly difficult to prescribe and perform relevant medical studies; however, third-party billing companies are attempting to mitigate the effect of RBMs and assist radiology practices by helping to organize reports and claims to maximize reimbursement.

“[RBMs] come up with reasons as to why a study is not necessary,” said Gerald Roth, MD, CEO and president of Tower Imaging Medical Group. “Insurance companies have delegated their authority to these people. They can stand at arm’s length. When you call up an insurance company and say, ‘I’ve been paying premiums for 10 years and need to have an MR because I can’t walk,’ they say, ‘We hired this third-party company that makes sure that only useful MRs are done. They use evidence-based medicine.’ It points to a third person as the person responsible for denying you service.”

Since insurance companies have delegated their power to these companies and RBMs aim to keep utilization rates low, radiologists have a difficult time earning reimbursement for relevant medical imaging studies. Because of this, radiology practices utilize technology and billing partners to help counter the growing demands of RBMs.

“I think more extensive clinical histories will help so that you can answer their questions,” said Roth. “From a technological standpoint, you want to have data, in terms of both the individual case before you approach the payor, and market data. It may be useful to have a way of figuring out how often they deny certain studies.”

However, technology alone cannot solve the issues at hand. Roth believes that the problems created by RBMs are arbitrary roadblocks. He argues that if radiology practices are able to navigate those obstacles, RBMs will simply be able to create new hurdles for providers to combat.

This is where billing companies aim to assist radiology practices. Although billing companies can’t necessarily overturn a RBM’s decision on a particular study, the companies ensure that providers present the most full, up-to-code claims possible.

“[Billing company] Zotec Partners deals directly with the insurance carriers that outsource to the RBMs, while its clients’—physicians and practice managers—front offices interact directly with the RBMs,” said Taylor Moorehead, regional partner of Zotec Partners’ west region. “Even with no direct front office interaction, Zotec’s back office metrics can identify process issues in the front office that ultimately affect collections. Therefore, Zotec can identify why the denials of an authorized claim are occurring, educate the client on the inefficiency, and work with them to make the necessary adjustments to the front office processes to maximize back office collections.”

There has also been recent legislation aimed at diminishing RBMs’ ability to deny claims. Recent health care reform passages place a limit on the medical loss ratio, a ratio of the total claims paid versus the premiums collected by an insurance company. The legislation mandates that medical loss ratio be at least 80% to 85%.

Even with all of these systems in place, Roth seems pessimistic about future interactions with RBMs.

“I’m not sure that it matters in the end,” said Roth. “Their goal is to find ways to reduce services. At some point, they just come up with more and more arbitrary criteria to say, ‘I don’t think this study is necessary.’ I’m not sure there’s a technological solution to this problem. I think the problem is an artificial roadblock put in the way. I don’t think technology will solve this artificial roadblock. They’ll just come up with a different roadblock.”

Billing management companies, however, continue to assist radiology practices in countering the negative effect of RBMs and are far more optimistic about providers’ ability to obtain the reimbursement deserved and execute the medical studies ordered.

“To address the increasing demands of RBMs, Zotec Partners will work to educate practice managers and physicians to put systems in place to verify benefits, check for preauthorizations or reauthorizations, and stay aware of the proper CPT code for the exam being ordered,” said Moorehead. “Together, billing companies and practice managers and/or physicians can work to counteract the impact of RBMs by optimizing and collecting every billable dollar from the payor and patient.”