Insurers review, trim MRI costs

Prospective review of requests for MRI examinations in workers'compensation cases is catching on among insurers eager to stallescalating imaging costs. One insurer projects annual savingsof $1 million due to either diversion of MRI requests to lesscostly imaging providers or recommendation of conservative treatmentrather than imaging.

The insurer, Industrial Indemnity, has funneled its MRI requeststhrough an externally supplied utilization review program for18 months. Developed by Workers' Compensation/ Casualty Services(WC/CS), a division of United HealthCare of Minneapolis, the programblends medical protocols and individual case factors to determineexam necessity.

About 2000 MRI requests have been reviewed by WC/CS for thesix insurers that use the program. Of the total, about 31% wasdiverted to conservative treatment instead of receiving the go-aheadfor the exam, said Glenda Gerrard, vice president of WC/CS.

With the average MRI exam costing about $1400, considerablesavings can be realized by reducing the number of scans or negotiatingdiscounts with preferred providers, Gerrard said.

Of the insurers participating in the review program, only IndustrialIndemnity has a preferred provider network for imaging. Nearly90% of its MRI requests are diverted to that network, resultingin a discount of about 40% per exam.

Imaging accounts for about 10% of Industrial Indemnity's workers'compensation nonhospital medical costs. Prior to its participationin the WC/CS program, the company's costs for imaging had increasedfrom $4.6 million in 1989 to $6.1 million in 1990.

Within the first six months of 1991, the company's costs dropped22% as a result of MRI review, according to Gregory Johnson, apartner with William M. Mercer, a national benefits consultingfirm. Mercer helped launch the review program along with WC/CSand Industrial Indemnity.

"MRI is a great technology, but it's not always used appropriately,"Johnson said. "This program minimizes some of the excesses."

The imaging review protocol used by WC/CS is similar to standardhospital utilization review programs. When a physician requestsan MRI or CT scan for a workers' compensation case, the claimstechnician contacts WC/CS for a precertification recommendation.

A MEDICAL PROTOCOL TAILORED to specific diagnoses is used to guideWC/CS as to the appropriateness of the MRI exam request. The protocolswere developed by WC/CS based on its experience with HMOs andPPOs, Gerrard said.

"Most imaging procedures in workers' comp are done tolook for surgical lesions," Gerrard said. "But firstwe need to have symptoms that point to the presence of those lesions.We prefer that conservative treatment be tried first, becausewhat we're mainly dealing with in workers' compensation is MRIfor lower back pain indications."

In general, eligibility for an MRI exam exists when patientsare clear surgical candidates after failure to respond to conservativetherapy, or when there is sciatica and corresponding nervous systemimpairment, she said.

"We also look at the specialty of the physician who isordering the exam," Gerrard said. "Because we're lookingfor surgical lesions, we want the surgeon to indicate whetherimaging is appropriate."

Fewer than 20% of patients diverted to conservative therapyreturn with a second request for MRI, she said. The appeal ratefor WC/CS decisions regarding the exams is less than 2%.

Although the utilization review program has found a niche inworkers' compensation, it is also attractive to other areas ofhealth insurance. At United HealthCare, imaging review is beingused among some of the company's group insurers, but in smallernumbers than on the workers' compensation side, Gerrard said.

"The difference between workers' compensation and indemnityis that with the latter, you are looking for more tumor masses,"she said. "You don't want to stand in the way of determiningwhether someone has a tumor."

Although cost savings is an important by-product of the imagingreview program, the goal is ensuring that the most appropriatecare is delivered, Gerrard said.

"It turns out that quality of care saves dollars,"she said. "Knowing the after-effects of surgery, we wantto make sure that surgery is only contemplated when appropriate.By the same token, you don't need high-ticket tests until surgeryis a certainty. That's where MRI comes in."

Within the next three years, most insurers will be incorporatingimaging utilization into their coverage policies, predicted Johnsonof William Mercer.

"Peer review is becoming more important in today's healthcare," he said.