Insurance-driven worklist guides teleradiology assignments

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In the busy world of radiology, automated worklist tools help ensure that the right study gets to the right radiologist in the least amount of time. For example, a worklist will direct an ordered exam to evaluate a patient’s meniscus to a musculoskeletal radiologist, while a cranial exam will go to a neuroradiologist for interpretation. However, an element lacking from the parsing capabilities of most worklists is the capability to filter exam interpretation assignments on the basis of insurance reimbursement.

A team of physicians from Staten Island University Hospital in New York has addressed the deficiency by developing a worklist tool that assigns studies based on a patient's insurance and a radiologist's credentialing status. Their work was presented last month in a scientific poster presentation at the 2008 Society for Imaging Informatics in Medicine (SIIM) conference in Seattle.

David Hirschorn, MD, and Leonard Lempert, MD, originally crafted their algorithm to keep studies for Medicare and Medicaid patients off the worklist used by any teleradiologist outside the United States. Hirschorn and Lempert noted that the Centers for Medicare & Medicaid Services (CMS) do not allow final interpretations by overseas radiologists, although many private payors do.

“As such, the teleradiologist needs a worklist based not only on the typical criteria of modality and body part or subspecialty, but also on the patient’s insurances,” they wrote. “Few if any RIS or PAC systems today have any such capability.”

The system queries the RIS database for exams ready for interpretation and then filters them on the basis of insurance credentialing.

“The results are displayed in a simple table, along with the list of all patient insurance, to allow the radiologist to visually check them as well,” the authors wrote.

In addition to screening out Medicare beneficiaries, the system also excludes exams for payors at which the teleradiologist is not yet credentialed—unless it is an emergency room exam, in which case the credentialing is not necessary.

The web-based tool allows the modification and viewing of this information, and is adjusted as necessary when new insurance plans are added to the practice, according to Hirschorn and Lempert.

The department uses the application 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 payors, and whether it is an emergency. In addition, the same data are used to distribute the excluded cases toward the local department’s radiologists.

“This system enables our department to maximize the benefit of the overseas radiologist by preferentially steering him toward cases for which payment is likely to occur,” Hirschorn and Lempert wrote.

Although their method of distributing exam workload based on insurance was “absolutely necessary for teleradiology reimbursement,” there is a secondary benefit to the application, the authors noted. The practice is now using the tool to steer non-emergent cases toward the radiologists that are credentialed at the payors associated with them.

“The insurance-based worklist can steer both the remote and local radiologists toward cases associated with payors at which they are credentialed, thereby increasing the likelihood of collection,” they concluded.