Original articleA Prior Authorization Program of a Radiology Benefits Management Company and How It Has Affected Utilization of Advanced Diagnostic Imaging
Section snippets
How Prior Authorization Works in RBMS
At HealthHelp and the other RBMs, PA programs generally use a 3-tiered system built around a call center. When a physician wishes to order elective outpatient, nonemergent MRI, CT, or PET on a patient, the physician must obtain approval from the RBM. Without this approval, the imaging examination might not be reimbursed. In some health plans and their arrangements with their RBMs, a disapproved imaging test can still be done and paid for, but this allows the RBM to determine the frequency of
Results from a Radiology Benefits Management Call Center
HealthHelp contracts with several large payers for its PA program. Table 1 shows the data from its call center operation for calendar year 2008. During that year, 404,612 requests for MRI, CT, or PET were processed by the center and handled by first-tier CSRs (first line of Table 1). They determined that 299,961 (74%) met at least one appropriateness criterion and approved the requests. In another 4,164 (1%), the criteria were not met, and the ordering physicians decided to withdraw the
The Gatekeeper Effect
Before the advent of the RBMs, physicians were generally free to order any imaging test they chose. The problem with such a system is that with the rapid changes that are constantly occurring in imaging technology and clinical indications, many physicians who were not trained as radiologists are not aware of which imaging studies may be the most appropriate [10]. And in some cases, the best course of action may be to do no imaging at all. In other cases, imaging may be ordered for questionable
Prior Authorization Effects on Advanced Imaging Utilization
One of HealthHelp's contracts is with Humana, a large payer based in Louisville, Kentucky. Humana and HealthHelp have kept careful records of the annual utilization rates of MRI, CT, and PET per 1,000 beneficiaries in their major markets after the implementation of the PA program. Before this time, Humana had been experiencing an annual utilization rate growth of approximately 10% for both MRI and CT and approximately 45% for PET. Note that these are estimates; they had not kept precise
Discussion
Several earlier non–peer-reviewed reports [1, 11, 12] suggested that RBMs can limit the utilization of high-tech diagnostic imaging. The only other peer-reviewed report on this subject that we are aware of is a recent one by Mitchell and LaGalia [13]. They used data from 3 regional health plans that contracted with another RBM, National Imaging Associates. After PA was instituted, utilization rates flattened out or declined initially, but in 2 of the 3 plans, they then resumed an upward trend.
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Cited by (0)
Disclosure: Drs Levin and Bree are consultants to HealthHelp. Ms Johnson is director of health care data analysis at HealthHelp. Dr Rao is a professor and chair of the Department of Radiology at Thomas Jefferson University, which has a contract with HealthHelp to provide peer-to-peer telephone consultations with ordering physicians.