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

Declining fee schedules, decreasing operating margins, and increasingly stringent compliance regulations create a need for intense scrutiny and optimization of a radiology organization's billing and collection procedures. The authors' goal was to analyze the effectiveness of departmental professional billing procedures, identify controllable factors, and intervene when they could be improved.

A detailed audit of professional claims and payments was performed for all patients who underwent abdominal-pelvic computed tomography (CT) during July 1999 (n = 717). The adequacy of indication for the CT examination as given by the referring physician and modified by the radiology staff, the time required for claim generation, and the status of reimbursement within 120 days were assessed by an interdisciplinary team. After an intervention was performed to improve adequacy of the available clinical indication, the audit was repeated in December 1999 (n = 710).

Despite a significant (P < .05) improvement in wording of clinical indications for billing purposes between July (68%) and December (85%), there was no significant change in reimbursement against gross charges. The vast majority of claims (97% in July, 99% in December) were generated in less than 30 days. At 120 days after the date of service, payments had been received that amounted to only 66% and 54% of discounted professional fees for July and December, respectively. For examinations performed in December, payment was delayed beyond contracted time periods in 138 cases (19%).

Optimum billing and collection for imaging studies is an increasingly complex task. Even when substantial efforts are devoted to eliciting the proper indication for the study, reimbursement remains low primarily because of payer delays.