A detailed audit of reimbursement for abdominal CT in an academic practice

Rationale and Objectives. Declining fee schedules, decreasing operating mar gins. and increasingly stringent compliance regulations create a need for i ntense scrutiny and optimization of a radiology organization's billing and collection procedures. The authors' goal was to analyze the effectiveness o f departmental professional billing procedures, identify controllable facto rs, and intervene when they could be improved. Materials and Methods. A detailed audit of professional claims and payments was performed for all patients who underwent abdominal-pelvic computed tom ography (CT) during July 1999 (n = 717). The adequacy of indication for the CT examination as given by the referring physician and modified by the rad iology staff, the time required for claim generation, and the status of rei mbursement within 120 days were assessed by an interdisciplinary team. Afte r an intervention was performed to improve adequacy of the available clinic al indication, the audit was repeated in December 1999 (n = 710). Results. Despite a significant (P < .05) improvement in wording of clinical indications for billing purposes between July (68%) and December (85%), th ere was no significant change in reimbursement against gross charges. The v ast majority of claims (97% in July, 99% in December) were generated in les s than 30 days. At 120 days after the date of service, payments had been re ceived that amounted to only 66% and 54% of discounted professional fees fo r July and December, respectively. For examinations performed in December, payment was delayed beyond contracted time periods in 138 cases (19%). Conclusion. Optimum billing and collection for imaging studies is an increa singly complex task. Even when substantial efforts are devoted to eliciting the proper indication for the study, reimbursement remains low primarily b ecause of payer delays.