Friday, April 30, 2010

10 Things an RBM(Radiology Benefit Manager) Won't Tell You

1. What their criteria is. Guidelines are posted on most RBM websites but criteria for decision making is not that transparent.

2. If the health plan will actually pay for the test or not. You can get prior authorization but the health plan has the final say as to whether or not they will pay for it.

3. The best way for you to submit clinical(telephonic, web or fax). They won't tell you what is the fastest way to get a response.

4. How to provide clinical. They will ask you questions about the patient but won't teach you how to do it.

5. The most common mistakes medical office staff make. There are a lot of common mistakes that staff are not allowed to share with you.

6. How to make sure your fax gets processed properly. There are key facts to know about properly faxing your prior authorization request.

7. They get frustrated too when callers are not prepared or faxed/internet requests are incomplete.

8. The medical provider can speak with a medical director at any time during the prior authorization process.

9. How to make your charting prior authorization friendly. It is easier for clinical reviewers to approve studies when medical office notes are complete.

10. The medical provider can write on the Rx, “add IV contrast if required”. For most health plans, the test must first be approved without IV contrast. It can be upgraded later if it can be justified.

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