All interventional radiologists are familiar with the difficulties that can accompany reimbursement claims. Understanding the nuances of insurance requirements and denial explanations takes up valuable time. Ezana M. Azene, MD, PhD, a vascular and interventional radiologist with Gundersen Health System, recently began working to review medical reimbursement claims, intervening and overturning denials for standard IR procedures. Below, Dr. Azene shared with IRQ some ways that IRs can avoid denial frustrations.
How did you get involved in reviewing medical cases?
Ezana M. Azene, MD, PhD
EA: It kind of came out of frustration, because I had a number of bad experiences with prior authorization failures or situations where, even after the procedure, a patient was denied reimbursement. Many times there was a lack of knowledge in the person I was talking to when I was doing peer-to-peer follow-up, and they often did not have any knowledge of the procedures or even the disease process that we were taking care of. I never once had an IR talking to me on the other side.
Finally I said, “If I’m complaining about this, maybe I should do something about it.” I looked into it and saw it was easy to become a medical file reviewer. I applied with a company—Medical Review Institute of America—and started doing file reviews.
What kind of medical cases do you review?
EA: I do mostly IR, and the most common cases that I see are treatment of pelvic congestion syndrome, uterine fibroid embolization and radio embolization. Occasionally I have a diagnostic radiology case to review, but I try to avoid doing those unless they’re really having trouble finding someone to do something like a breast MRI, for example.
What suggestions would you give for other providers submitting claims?
EA: You need to know what the insurance company requires in documentation to have approval for these cases and, if it’s possible, try to identify your most restrictive set of criteria. If you can figure out which insurance company requires the most in terms of documentation, then try to consistently provide that information in your notes across the board.
Usually they will list certain criteria that have to be present before they approve a procedure, and it really helps to have those clearly articulated in your clinic notes—because then you can completely bypass the need for a medical file reviewer, as the insurance company will just approve it up front.
But sometimes I will review a case and make an argument for why the payer or insurance company should consider a procedure medically necessary, despite their policy. I will explain why their policy is incorrect or based on old data. I do that a lot for PCS and UFE.
Have you learned anything through this work that has surprised you?
EA: Yes—sometimes the process really boggles the mind. I’ll see a decision rendered by the person who did the file review before me and they clearly haven’t even read the documents that have been provided. Sometimes it’s clearly stated in the documentation that the procedure is medically indicated based on the criteria that the payer has set forth, but sometimes I guess it’s missed, or they don’t take the time to read everything. Those are pretty easy, because I can just note that the clinic notes clearly state the patient has a medical necessity. But I was surprised by how often that happens.
Who typically performs those initial reviews?
EA: Usually the first review is done by a nonphysician. If there’s a denial, it may or may not get an automatic review by a physician, sometimes an internal physician employed by the insurance company. Usually when it gets to me, it’s on appeal, and with that they want to find an independent third party to evaluate the medical file.
What kind of time commitment is required for these reviews?
EA: I don’t do a lot, and it varies from month to month depending on how available I am and whether I’m on call. I would say on average I do somewhere between one to four cases a month. When you’re first starting and getting used to the process and system it can take an hour, but once you’re experienced, then you can finish a case in anywhere from 10 minutes to half an hour depending on how complicated it is. There are cases you see over and over again—such as UFE or PCS—and you can use the reports that you wrote previously and essentially copy and paste them into the new report and update references as necessary.
Have you met other IRs who do review cases like this?
EA: No, but there’s definitely a demand for it. There are always plenty of cases for me to review, and I turn a lot down because I don’t have the time.
You’ve used the word charity work to describe this—why?
EA: It’s not something that you do to reward yourself financially—it definitely doesn’t pay well. I don’t think I’ll be doing it indefinitely, but I do plan to continue for now. It has been a great learning experience for me—it’s made my documentation better, because now I know from the other side what I need to document to get the best chance at reimbursement.
