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Insurance denials of MRI's…..

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  • Avatar Ykcor 
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    Way too many MRI are being ordered as it is. Getting an MRI because there is radiculopathy is unnecessary if you haven’t done first line of treatment like PT and NSAIDS. If you haven’t done the first line of treatment, you get the MRI which shows a disc and then you send to therapy. I would think many patients would like to avoid the cost of an MRI unless it is necessary

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    Try telling the blue collar worker in intense pain and unable to walk, that the end results after six months of conservative therapy vs intervention therapy is equivalent for HNP (other than caudal equinal syndrome)  especially if he doesn’t have some short term disability insurance.

    #213188 Reply
    Avatar HandFellow 
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    We aren’t talking about the 6 months patient here that failed conservative management. OP was talking about someone with radiculopathy new onset that hadn’t waited 6 weeks yet. For me, an MRI tells me when I need to operate, so getting one right away doesn’t make sense. But failed 6 months of conservative management? Get the MRI and do surgery, no doubt.

    I work next to another doc who uses an NP. You should see his algorithm: pain with normal X-ray? MRI. That’s why they are harder to get now.

    #213199 Reply
    Zzyzx Zzyzx 
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    We do them in our ER. Drives me insane.  Part of it is because we do see a high number of professional athletes, and their coaches insist, which is funny, because ortho never wants them on follow up.

    My guess is insurance never covers them ha ha.

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    any pro athlete with an “on the job injury” has to be covered by their workcomp.  have your ED billing dept look at the reimbursements for these emergent MRI’s; if there is a high number of denials then you might have an argument to take to admin.

    I believe the only same day MSK MR’s we did for our pros and collegiates were for spinal injuries, knee dislocations, neuro stuff (seizures, ICH, …)

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    Are internationally-based athletes or those who make money by endorsements are covered by worker’s comp? I’m pretty sure worker’s comp is only for W2 employees in US-based jobs, no? The international ones come with weird travel policies. If they are covered by worker’s comp, that’s great, but I don’t think so. I meant ortho doesn’t want the MRI, not the patient! They are happy to have cool, pro athlete patients.

    Sure. That’s medically correct. That’s not what we do, unfortunately. I don’t agree with our standard. I’m not sure what your point is.

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    yes if international with US work visa, if not then you probably bill the travel policy or medicaid (most states have an emergency provision in their medicaid for non-US citizens).  again, check with your billing dept and if you aren’t getting reimbursed for most of these MRI’s via the travel policy then you have a case to be made to admin.  I don’t follow what you mean by endorsements, I’ve treated many pros and teams with endorsements and they all are covered under wcomp assuming the injury occurs at work.  I don’t get why the ED standard is significantly different than sports med standard of care.

     

    It’s psychosomatic. You need a lobotomy. I’ll get a saw.

    #213210 Reply
    Avatar snowcanyon 
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    We do them in our ER. Drives me insane.  Part of it is because we do see a high number of professional athletes, and their coaches insist, which is funny, because ortho never wants them on follow up.

    My guess is insurance never covers them ha ha.

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    any pro athlete with an “on the job injury” has to be covered by their workcomp.  have your ED billing dept look at the reimbursements for these emergent MRI’s; if there is a high number of denials then you might have an argument to take to admin.

    I believe the only same day MSK MR’s we did for our pros and collegiates were for spinal injuries, knee dislocations, neuro stuff (seizures, ICH, …)

    Click to expand…

    Are internationally-based athletes or those who make money by endorsements are covered by worker’s comp? I’m pretty sure worker’s comp is only for W2 employees in US-based jobs, no? The international ones come with weird travel policies. If they are covered by worker’s comp, that’s great, but I don’t think so. I meant ortho doesn’t want the MRI, not the patient! They are happy to have cool, pro athlete patients.

    Sure. That’s medically correct. That’s not what we do, unfortunately. I don’t agree with our standard. I’m not sure what your point is.

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    yes if international with US work visa, if not then you probably bill the travel policy or medicaid (most states have an emergency provision in their medicaid for non-US citizens).  again, check with your billing dept and if you aren’t getting reimbursed for most of these MRI’s via the travel policy then you have a case to be made to admin.  I don’t follow what you mean by endorsements, I’ve treated many pros and teams with endorsements and they all are covered under wcomp assuming the injury occurs at work.  I don’t get why the ED standard is significantly different than sports med standard of care.

     

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    Umm…these folks are here for competition, and, as noted, have their own travel policies.  They do not have a US work visa. They are not working in America; they are part of a team competing in the USA. You must be working with domestic teams, which is not our situation for the most part. These are not basketball players or football players or the like. There are other models of payment for professional athletes. Not everyone is W2. These are, for the most part, internationally based athletes. I’m not the biller so I don’t know whether the domestic athletes are covered by worker’s comp or private insurance or nothing at all.

    It’s the hospital’s issue, not mine, to deal with unreimbursed MRIs. In no way does this affect me. So I don’t care at all about the billing. You seem to care about it for some reason.

    #213216 Reply
    Avatar jz 
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    Patients with obvious cervical or lumbar radiculopathies and severe pain, they want plain X-rays plus six to eight weeks of conservative Rx before getting scan.

    I (ER doc) have personally had two cervical radiculopathies.  One lasted 3 weeks and the other 13 months.  Total costs= $0.

    #213217 Reply
    Liked by snowcanyon
    Avatar burritos 
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    If patients are wanting an imaging study for “because I want to know” indication vs clinical indication, then they should be responsible for the cost if no actionable finding is identified.

    #213220 Reply
    Liked by MaxPower, jz
    Avatar jacoavlu 
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    MRI breast? Forget about ordering one, even though there is a State Law here in Alabama that on a mammalogram radiologist’s report involving a dense breast, they have to suggest having this test.

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    It is unlikely that the law mandates suggestion of an MRI, or other imaging. Many states have passed breast density reporting legislation, which typically mandates the facility notify women who have “heterogenously dense” or “extremely dense” parenchyma, because the sensitivity of mammography is known to be lower for these women.

    The Finance Buff's solo 401k contribution spreadsheet: https://goo.gl/6cZKVA

    #213348 Reply
    Avatar Hawkeye225 
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    Seems to be getting harder to get insurance to approve MRI requests. Patients with obvious cervical or lumbar radiculopathies and severe pain, they want plain X-rays plus six to eight weeks of conservative Rx before getting scan. Unfortunately, patients in USA want fast results. Myself, being in private practice, I don’t have time to do face to face appeals, so I just refer the patient to a neurosurgeon, which ultimately costs the insurance company more money.

    MRI breast? Forget about ordering one, even though there is a State Law here in Alabama that on a mammalogram radiologist’s report involving a dense breast, they have to suggest having this test. (Apparently A state legislature’s wife had a breast cancer missed on a regular mammalogram several years ago).

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    It’s pretty standard that 6 weeks of active PT or chiro therapy and NSAID’s is required prior to obtaining a non urgent spine MRI.  Studies show that somewhere around 90% of sx’s resolve within that time.  If there is a neuro deficit (weakness, etc.) then it is approved immediately.

    Breast MRI is simple to obtain as long as there are reasonable reasons such as a lump without an imaging correlate, known cancer or high risk, etc.

    The vast majority of problems I’ve seen with this is improper documentation.  If it’s documented properly, it’s approved.  One must know or have access to the guidelines of the insurance company.

    #213349 Reply
    Avatar Tim 
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    “Aha…I was thinking more along the lines of MLB, NFL, NBA, and NHL.” Throw in soccer too.
    Virtually all have a Team Doc that is Ortho dept chair or high rep doc that has an academic and large hospital system behind them. Logistics of the schedule can play a big part. Away game or road trip coming up? Might send them in because it’s “open”. That’s not a “walk in”. Every pro team will have an ortho travel to away games as well.
    Tennis, golf, skiing, track don’t have Team Doc’s. I can see that happening then. In every case the motive is Go or No Go, further damage or just pain. PT and healing isn’t on the table. That’s later.

    #213357 Reply
    Vagabond MD Vagabond MD 
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    I lost my cool one night on a crazy family and pointed out when their little Johnny made as much money as Lebron, he could buy a hospital and get his knee MRI. until then they had 2 options: leave now with crutches or leave in a squad car with a trespassing charge (and crutches). 

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    Professional athletes are usually my go to for examples and how even professional athletes don’t get emergent soft tissue/joint MRIs. Sure, they usually get them the next day but that’s not my point. If a $100M knee can’t get an emergent MRI in the ED then the chance that Joe Blow (who was told by urgent care to come straight to the ED for an MRI) can get one is going to be pretty slim…zero, actually.

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    Professional football players get their MRIs on Sunday nights, after the game. It’s not handled in the ER, and they don’t pay for them.

    "Wealth is the slave of the wise man and the master of the fool.” -Seneca the Younger

    #213458 Reply
    Vagabond MD Vagabond MD 
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    To the OP, the literature supports conservative therapy prior to imaging for radiculopathy, unless there are “red flags” (like suspected cancer, infection, myelopathy, etc.). Insurance guidelines are based on the literature, and these same guidelines will be applied to Medicare patients starting in 2020. If a patient cannot wait or does not want to wait, they are always welcome to pay for their own scan. We discount for patients who will pay cash at the time of service.

    "Wealth is the slave of the wise man and the master of the fool.” -Seneca the Younger

    #213461 Reply
    Avatar burritos 
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    I usually will order MRI’s for my cops and firemen even if the indication is borderline. I’ll also order it for people who are willing to skip insurance and just pay cash.

    #213471 Reply
    Avatar Panscan 
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    ^ sounds really stupid.

    #213561 Reply
    Liked by Lordosis
    Avatar Redpops46 
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    Sorry but I would have to disagree with the OP here. I think both denials sound reasonable. I doubt a surgeon is going to operate immediately after an MRI for radiculopathy in the absence of other associated pain. Unless imaging prompts something actionable, what’s the urgency?

    Also, dense breasts is NOT an indication for MRI.

    #215198 Reply
    Avatar Redpops46 
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    Sorry typo- other concerning symptoms, not pain.

    #215199 Reply

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