Patients involved in automobile accidents often require MRIs and CT Scans, which allow healthcare providers to discover the extent of their patients’ injuries and plan a future course of treatment.  Providers most commonly prescribe MRIs for the cervical and lumbar spine upon their patients’ complaints of back pain and objective findings such as limited range of motion.

Whether a healthcare provider prescribes an MRI or CT scan for the spine, brain, or an extremity, billing these services to no-fault insurance companies can be complicated, and—if done incorrectly—can lead to claim denials.  To ensure the timely and full payment of your claims, certain guidelines must be followed.

Please take a few moments to review the information below, where we have provided detailed information pertaining to no-fault billing of MRIs and CT scans.  If you would like to know more about MRI and CT scan no-fault billing, call us for a complimentary consultation at (516) 427-5400.

Fee Schedule for Multiple Procedures

According to the New York State Workers’ Compensation Medical Fee Schedule, effective June 1, 2012, the following adjustments apply to the performance of all diagnostic radiology procedures:

1, For two contiguous parts (within the same classification of imaging procedures on a single patient), the charge shall be the greater fee plus 50 percent of the lesser fee.

2, For two remote parts, the charge shall be the greater fee plus 75 percent of the lesser fee.  Bilateral procedures are considered remote parts.

3, For three or more parts, whether contiguous or remote, the charge shall be the greater fee plus 75 percent of the lesser fees.

Seeking Reimbursement for MRIs

Insurance companies often verify claims by requiring medical providers to submit to them results of MRIs performed on the patient.  At their requests, insurance companies are entitled to copies of MRI films.

When an insurance company requests MRI films to verify a no-fault claim, and a medical provider furnishes satisfactory reproductions in lieu of the original films, the provider may charge the insurance company $5.00 for the first sheet of duplicating film or the first compact disk (“CD”), and three dollars for each additional sheet of film or CD.

If the medical provider furnishes the original MRI films, then the provider may not charge the insurance company a fee for the films, and the company must return the films to the provider within 20 days of receiving them, if the provider so requests.

If an imaging facility seeks payment for an MRI from an insurance company, it is not uncommon for the company to request a copy of the “narrative report” of the physician who ordered the MRI as a means to investigate whether the MRI was medically necessary.  Insurance companies are entitled to these reports if they so request.

Keep in mind, under the new regulations, an insurance company may deny the claim outright where 120 days have elapsed from the date of the request, and the medical provider has neither proffered the requested verification nor come forward with “written proof providing reasonable justification for the failure to comply.”  In sum, when an insurance company requests these reports, or the results of an MRI, it is important to provide them with the requested documents before 120 days from the date they were requested.

Denials by Insurance Carriers for MRIs After an Automobile Accident

Insurance companies often contest the need for MRIs and CT scans, usually arguing that diagnostic testing was performed too soon after the accident (i.e., patients should have time to improve through conservative treatment before submitting to a costly diagnostic test).

Contesting the necessity of these tests usually occur through a peer review, where insurer-paid physicians determine whether an MRI or CT scan performed on a patient was medically necessary.

Generally as per the “BRAIN MRI”, physicians conducting a peer review on behalf of the insurance carriers conclude the following: An MRI of the brain is considered medically necessary when the patient sustained direct head trauma, lost consciousness, or experienced an alteration in mental status.  An MRI is also considered necessary when there is reason to believe that a post-traumatic, space-occupying intracranial lesion is present.

During an initial neurological examination, a cranial nerve examination should be conducted before ordering an MRI.  In cases of mild head injury, with no loss of consciousness or neurological deficits, a CT scan would be medically necessary if the patient’s headaches persisted.

Generally as per the “SPINE”, physicians conducting a peer review on behalf of the insurance carriers conclude the following: An MRI of the spine is considered medically necessary when there is any one of the following:

1, Suspected spinal fracture and/or dislocation secondary to trauma (if plain films are inconclusive);

2, Suspected spinal cord injury secondary to trauma;

3, Persistent back or neck pain with radiculopathy, evidenced by pain and objective findings like motor or 4, reflex changes in the specific nerve root distribution, and no improvement after six weeks of conservative therapy;

5, Severe back pain (e.g., requiring hospitalization);

6, Progressively severe symptoms despite conservative management;

7, Rapidly progressing neurological deficit;

8, Major motor weakness; or

9, Clinical evidence of spinal stenosis.

10, The L-Spine MRI was perfomed too soon and should have been perfomed 4 to 6 weeks after the accident

Generally as per the “EXTREMITY”, physicians conducting a peer review on behalf of the insurance carriers conclude the following:

A shoulder MRI is generally considered medically necessary for indications of suspect intra articular loose body, evaluation of avascular necrosis in the humeral head, and indications of shoulder instability or labral tear.

An MRI is also medically necessary when  symptoms are not responsive to a treatment plan of physical therapy, non-steroidal anti-inflammatory drugs, and home exercise.  Additionally, shoulder symptoms indicate a need for an MRI upon finding at least two of the following: anterior or posterior shoulder instability; external rotation pain or weakness; impingement signs; loss of abduction; and persistent pain with activity.

Burden of Medical Necessity Courts have struggled with two major issues pertaining to claims by radiologists who perform MRIs and CT scans.

First, there is the issue of whether services performed were medically necessary under the circumstances.

Courts have found that medical necessity for an MRI exists when the MRI is reasonable and necessary to expedite or impact the diagnosis of the patient, the patient’s work status, or his or her clinical outcome. Courts have also found that medical necessity exists when conservative treatment (e.g., physical therapy, spinal manipulation therapy, etc.) fails to improve the patient’s condition.

Second, there is the issue of whether the medical necessity defense is available against radiologists, even though they perform MRIs and CT scans pursuant to a prescription from a referring physician.

In West Tremont Medical Diagnostic P.C. v. GEICO, the Second Department addressed the second issue, holding that the medical necessity defense is indeed available against diagnostic testing centers.  The court opined that if the defense of lack of medical necessity could be asserted against an eligible injured person, it follows that it can be asserted against a medical provider, no matter if the provider performs diagnostic testing pursuant to a prescription.

Disclaimer: Please be advised that the purpose of this information about MRI and CTs  medical procedures is none other than to make the reader aware that at No-Fault Billing.com we are experts in no-fault billing and collection. At no time this information should be used for any other purpose. Its solely the responsibility of the treating physician to determine which medical procedure is medically necessary and justify such medical necessity. Prescribing MRIs and CTs to a patient is a sole decision of the treating physician. This information should never be used by any physician to plan or administer any medical treatment.

We specialize in no-fault billing and collection.  For more information about MRI and CT scan billing, please call us at (516) 427-5400 for an immediate, free consultation.