Precertification rules could give MR the blues

April 21, 1993

In what could be a harbinger of the future of health-care reform,a Blue Cross/Blue Shield plan in New York has begun requiringprecertification for MRI scans. Precertification is not new to managed care plans such as healthmaintenance organizations. But

In what could be a harbinger of the future of health-care reform,a Blue Cross/Blue Shield plan in New York has begun requiringprecertification for MRI scans.

Precertification is not new to managed care plans such as healthmaintenance organizations. But a growing number of indemnity insurersare adopting preapproval guidelines as a means of cutting costs,and MRI scans often end up on precertification lists.

Blue Cross/Blue Shield of Western New York implemented a precertificationprocess at the beginning of the year that requires physiciansto receive approval by phone from Blue Cross/Blue Shield beforeordering certain MRI scans. The insurer has not made any otherchanges in its menu of reimbursable MRI procedures.

MRI brain scans done to rule out brain tumors are always reimbursableand do not require precertification, said Nora K. McGuire, vicepresident of utilization management for the insurer. At the otherend of the spectrum are scans of the hand and foot, which arenot usually reimbursed by the plan.

In between are shoulder and knee scans. Precertification willbe granted for such procedures if a patient has shown persistentsymptoms, such as pain, blood or fluid in the joint, for morethan six weeks, McGuire said.

The precertification rules were implemented because of concernabout the rising number and increasing cost of MRI scans beingperformed in the insurer's area of coverage, which consists ofeight counties in the Buffalo, NY region. Increased utilizationis due to the growing number of scanners in the area, McGuiresaid.

Blue Cross/Blue Shield is conducting outcomes research to determineif the precertification process has an effect on payments, accordingto McGuire.

"What we're looking at and are going to evaluate in sixto nine months is whether the process we've put in place is eliminatingunnecessary MRIs," McGuire said. "We want to make surethat we're only paying for appropriate, medically necessary MRIs."

Blue Cross/Blue Shield also lowered its reimbursement paymentfor MRI scans from $750 to $550, McGuire said.

"It was determined that our allowance was too high, andwe lowered it accordingly," she said.