Insurers Are Cracking Down on Imaging Costs : Using multimodality-only providers, 'soft denial,' and preauthorization are among insurers' strategies.


Fed up with rising imaging costs, insurers are seeking—and finding—novel ways to stem the tide.

On average, costs of imaging—especially high-tech procedures, such as MRI, CT, and magnetic resonance angiograms—have been going up 20% a year for the last several years, according to Thomas Dehn, M.D., cofounder of National Imaging Associates, a radiology utilization management firm in Hackensack, N.J.

“Some will say it's the aging of the population, but the key issue is really demand,” said Dr. Dehn, the company's executive vice president and chief medical officer. “Patients are bright. They're good consumers. They want a shoulder MRI if their shoulder hurts.”

Physician demand is also an important part of the equation, he said. “If you have physicians who want increased [patient volume] in their offices, it is possible that rather than spending cognitive time, for which they're poorly reimbursed, they may choose to use a technical alternative.”

For example, a doctor trying to figure out the source of a patient's chronic headaches “may get frustrated and refer the patient for an MRI of the brain, just to show them they're normal,” Dr. Dehn said. “The treating physician knows in the back of his mind that there isn't going to be anything [there], but it will calm the patient down.”

As to which physicians are responsible for the increase in imaging, the answer depends on whom you ask. The American College of Radiology contends that the growth is largely due to self-referral by nonradiologists who have bought their own imaging equipment. But others say that all specialties are doing more imaging, largely because of improved technology and the improvement in care that it brings.

Whatever the reason that more scans are being done, insurers have decided they've had enough. Take Highmark Blue Cross and Blue Shield, a Pittsburgh-based insurer whose imaging costs have risen to $500 million annually in the last few years.

One Highmark strategy for paring down its imaging costs is to develop a smaller network of imaging providers. To be included in Highmark's network, outpatient imaging centers must now offer multiple imaging modalities, such as mammography, MRIs, CTs, and bone densitometry.

“We were seeing many facilities that were single modality—just CT or just MRI,” said Cary Vinson, M.D., Highmark's vice president of quality and medical performance management. “They were being set up by for-profit companies to siphon away high-margin procedures from hospitals and other multimodality freestanding facilities. We were seeing access problems for referring physicians because the single modality centers were outcompeting the multimodality centers, and they couldn't keep up.”

In addition to credentialing the imaging centers, Highmark is going to start requiring providers to preauthorize all CT, MRI, and PET scans. At first, while everyone adapts to the new system, the preauthorization procedure will be voluntary and no procedures will be denied. But eventually—perhaps by the end of this year—the preauthorization will become mandatory, Dr. Vinson said.

Harvard Pilgrim Health Care (HPHC) of Wellesley, Mass., is taking a slightly different approach. Instead of mandatory preauthorization, HPHC is using a “soft denial” process in which physicians must call for imaging preauthorization, but they can overrule a negative decision if they want to.

“We made a decision based on our network being a very sophisticated, highly academic referral environment, that a hard denial program might not be best way to go,” said William Corwin, M.D., the plan's medical director for utilization management and clinical policy. “Instead, we elected to use a more consultative approach.” The program started in July, so results aren't yet available, he noted.

Plans that start a preauthorization program must first figure out who should be authorized to perform scans. At Highmark, the plan tried to be as inclusive as possible, Dr. Vinson said. “In some cases within a specialty, we tried to determine who was qualified and who was not,” he said. “For instance, for breast ultrasound, we listed radiologists, but we also included surgeons with breast ultrasound certification from the American Society of Breast Surgeons.”

Highmark ran into a turf battle as it tried to credential providers. In this case, the American College of Cardiology and the American College of Radiology “definitely have differences of opinion about who's qualified and who's not” when it comes to cardiology-related imaging exams, Dr. Vinson said. “Highmark took the approach of accepting either society's qualifications. They clearly wanted us to decide between the two, and we would not do that.”

To design their preauthorization programs, both Highmark and Harvard Pilgrim worked with National Imaging Associates, which now has “more than two dozen” clients nationwide and is active in 32 states, said Dr. Dehn. He predicts that at least one more specialty will come into the picture, as more and more molecular imaging is being done to design tumor-specific antibodies. “You may have immunologists who are doing diagnostic imaging.”

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