Best practice guidelines earn praise, criticism from radiology benefit managers

April 30, 2009

A white paper on imaging preauthorization guidelines produced by the American College of Radiology and the Radiology Business Management Association has drawn mixed reactions, particularly among radiology benefit managers. The benefit managers agree that management programs may lack consistency and add costs. But they also worry the guidelines may weaken efforts to control imaging overutilization.

A white paper on imaging preauthorization guidelines produced by the American College of Radiology and the Radiology Business Management Association has drawn mixed reactions, particularly among radiology benefit managers. The benefit managers agree that management programs may lack consistency and add costs. But they also worry the guidelines may weaken efforts to control imaging overutilization.

In the position paper released April 16, the ACR and Radiology Business Management Association said they feared that a proliferation of radiology benefits management (RBM) programs is turning into bureaucratic overkill. Rather than cutting overhead costs to payers, referring physicians, and radiologists, RBMs might be adding to them, according to the ACR/RBMA white paper. The authors responded with a list of best practices defining when and how imaging preauthorization makes sense.

The issue of how radiology responds to the advance of RBMs and prior authorization is growing in importance. A line item in the proposed budget for the fiscal year 2010 sent to Congress by the Obama administration calls for Medicare to rely on radiology benefit managers to contain costs. The budget assumes five-year savings of $70 million and 10-year savings of $260 million through prior authorization.

The ACR does not endorse RBM programs or their imaging preauthorization approach, it but agrees that they can play a role in keeping utilization of high-tech imaging modalities in check. That role should be dictated by medical need, however, and not by economic or bureaucratic prerogatives, said Dr. Christopher G. Ullrich, chair of the ACR Managed Care Committee.

"This represents a consensus between the ACR and RBMA about good business practice," Ullrich told Diagnostic Imaging.

Some of the clinical and administrative guidelines stipulate, for instance, that the preauthorization process should cover a family of codes instead of specific CPT codes or that physicians or nurses with imaging expertise should be the RBM decision makers. The guidelines also call for accreditation of equipment and technologists, and approval protocols for outpatient studies prescribed after hours or on weekends when RBMs are closed.

Not endorsing the RBM approach is not the equivalent of rejecting it, said Ullrich, a private practice neuroradiologist in Charlotte, NC. RBMs have substantial traction in the marketplace and have become a fact of life for radiology practice. But their use brings up multiple issues, such as confusing rules; frequent denial of payments for medically warranted studies; and lack of proper administrative cost assessments that frustrate both providers and payers.

The guidelines attempt to resolve these problems, but the ACR still prefers other alternatives, such as order entry decision support and referring physician education, Ullrich said.

"Radiologists want clear and medically defined policies, low operating or administrative costs, and predictable payments. Just simple, basic things," he said.

While some of the white paper recommendations have merit and are appropriate, others are clearly designed to minimize the impact of prior authorization and the application of evidence-based criteria, said Don Ryan, president and CEO of CareCore National, a radiology benefits management company.

"The suggestion that simply making ‘decision support' tools available to referring physicians and radiologists will significantly reduce inappropriate utilization is not supported in the data," Ryan said.

Some small, highly focused, and controlled pilot programs have demonstrated limited impact. But to assume that this process can be successfully applied across 600,000-plus practicing physicians is not practical, Ryan said.

Many specialty societies, including the ACR and the American College of Cardiology, have had comprehensive appropriateness guidelines available for a number of years and have encouraged their members to use them. While everyone involved would like to see a greater degree of imaging discipline, just the opposite is happening, he said.

"One can easily make a case that broad-based ‘self-policing' has not worked on Wall Street, in the legal and accounting professions, in the banking world, and in our healthcare system," Ryan said.

The issue of inappropriate utilization goes beyond self-referral, Ryan said. He welcomed the publication of the document, however, as a signal of the ACR's interest in opening a dialogue around the issue.

"We are open to that dialogue and have been for some time," said Dr. Greg Allen, executive vice president and chief medical officer of Tennessee-based RBM MedSolutions.

Allen explained that MedSolutions and the ACR have wrestled around managed care issues for years, but they have always found common ground. The guidelines outline principles his company has observed -- sometimes exceeded -- and even though there might be some disagreements on several points, there is also a will to carry on the discussion, he said. Allen concedes the need for consistency in RBM programs but not at the expense of their effectiveness or allure to customers or beneficiaries.

"I'm glad that the ACR has taken a step to outline some of these parameters from their perspective," Allen said. "It's an acknowledgment that the RBM activities are in fact working and obviously very much front and center with regard to the effective techniques to manage utilization. Otherwise, I don't think the ACR would have devoted this kind of effort to the topic."