Based on a recent study published in the Journal of the American College of Radiology, radiology workflow solutions automatically alert radiologists of all new exams that call for custom protocoling based on a health plan’s denial conditions. However, the exclusion of these denial conditions in utilization management for advanced diagnostic imaging won’t lead to an increase in imaging.
For fully-realized and effectively designed radiology workflow solutions do away with errors preceding data reporting, leading to a reduction in claim denial follow-up. Claim denial has made its way to the head as health insurance plans have applied broad-based utilization management systems whose process includes denial provisions. Therefore, in an effort to control medical imaging costs, health plans may (and have) refuse to pay for requested studies that have been performed.
The findings of the study are in harsh contrast with the view that denial provisions, which decline payment for studies not regarded suitable by the preauthorization system, diminish use, and that allowing clinicians to order exams not certified by the system would lead to utilization growth.
“A collaborative utilization management system that does not deny payment, interfere with the doctor-patient relationship, or force test substitution could reduce the friction associated with utilization management without necessarily increasing expenditures on imaging,” wrote Jeffrey D. Robinson, MD, of University of Washington, Seattle, peers, and authors of the study.
According to Health Imaging, results of the study were predicated on a retrospective review of records from HealthHelp, a national imaging utilization management company that deals with health insurance plans.
“The company’s process is similar to other radiology benefits management systems in that it sets rules for which exams are considered appropriate based on indications and suggests alternatives, if a requested study doesn’t meet guidelines. However, unlike other systems there is no denial provision, and a provider may go ahead with a request that isn’t indicated,” explained Robinson.
The researchers examined a health plan that used a no-denial pre-authorization system for CT, MRI, PET and nuclear cardiac imaging in all but four of its geographic markets, which turned into the experimental group. They retrospectively reviewed 247,117 advanced imaging requests 21 months before and 16 months after the eradication of the denial provision in the experimental group.
Compared with matched control markets, in which a shared model was used for the entire study period, the utilization growth rate in the experiment group declined slightly by 0.10 requests per 1,000 covered lives, reported the authors. Approval rates however remained unaffected.
Robinson and colleagues recommended that the educational process provided by the authorization consultations worked against the natural tendency of people to take what they can get, even if at the end of the process an imaging request is approved regardless of its appropriateness based on guidelines.
The researchers theorized that a joint consultation between a radiologist and ordering physician, without the threat of denial of payment, would not lead to higher imaging utilization.
They believe that an educational process that requires an imaging professional to provide a rationale for appropriate imaging “would counterbalance the natural tendency of people to get as much as they can until someone says, “No.”
Precisely capturing medical coded data with a radiology workflow solution is critical to make sure that radiology departments obtain optimum repayment and collect comprehensive benchmarking data to help improve clinical and financial decision making, facilitate health policy approvals, and track patient trends.