A system presented at the SIIM meeting is able to develop work lists based on a patient’s insurance and a radiologist’s credentialing status, important considerations as more and more studies are interpreted away from central offices and facilities try to maximize reimbursement.
A system presented at the SIIM meeting is able to develop work lists based on a patient's insurance and a radiologist's credentialing status, important considerations as more and more studies are interpreted away from central offices and facilities try to maximize reimbursement.
The original inspiration for the system was to keep studies for Medicare and Medicaid patients off the work list used by a radiologist who was based outside of the U.S. CMS does not permit payment for interpretations performed on non-U.S. soil, although most private payers do. Few, if any, RIS or PACS today have the ability to filter work lists based on insurance status, according to the authors of the study, Drs. David S. Hirschorn and Leonard Lempert, both of Staten Island University Hospital.
Their solution, described in a poster presentation, was to develop an algorithm that removes CMS studies from a work list developed for an overseas teleradiologist reading night studies for the hospital.
The algorithm includes a table that specifies whether the patient's insurance coverage is from CMS and whether the teleradiologist is credentialed for the plan. A web-based tool allows users to modify and view the payer information and to adjust it as necessary when new payers are added.
The table is then used to filter out cases from the overseas teleradiologist's work list based on whether CMS will pay for them, the radiologist's credentialing status for the payers, and whether it is an emergency case.
Later, the same system was adapted to steer nonemergency cases toward radiologists who are credentialed by the payers that are associated with the cases. The system increases the likelihood of payment for all claims from the department, the authors said.