RBMs Are Transparent, Accredited: Exec Responds

Diagnostic imaging continues to be one of the fastest growing segments in health care, and it contributes to the ever increasing cost of health care in the United States. Spending on high tech imaging has surpassed 100 billion dollars annually. According to the Congressional Budget Office, as much as 30 percent of medical services including diagnostic imaging are not medically necessary.

Based on these realities, Radiology Benefit Management companies (RBMs), or Specialty Benefit Management companies, have worked with third-party payers to establish methods to ensure that these tests are used only in those cases that demonstrate medical necessity. To determine medical necessity, RBMs generally require a medical necessity review of requests for diagnostic imaging exams.

Rigorous state regulatory requirements govern RBMs and health insurance plans including how precertification of requests for high tech imaging is conducted. Certification and accreditation agencies (such as URAC and NCQA) also have programs in place to oversee the quality and transparency of the medical policies or criteria used to determine medical necessity. It would be a challenge to find a health plan or RBM that does not have the seal of at least one accrediting agency.

In the April 25 Diagnostic Imaging article, “Most Imaging Insurance Denials Due to Prior Authorization,” Gail Rodriguez, executive director of the Medical Imaging and Technology Alliance, and coverage of a report produced by the nonprofit Patient Advocate Foundation incorrectly infer the following:

- Radiology benefit management companies and/or health plans are not transparent with the criteria used to determine medical necessity of high tech diagnostic imaging.
- Evidence-based, physician-developed appropriateness criteria are not used to develop the criteria used by radiology benefit management companies and health plans.
- When a denial is issued, the rationale for that denial is not clear.

While NCQA and other oversight entities require RBMs to make their clinical criteria available to providers and their patients upon request, CareCore National and other RBMs take this a step further by publishing their clinical criteria on their company websites. At CareCore National, we review and update all of our clinical criteria at least annually. When appropriate, the criteria are updated more frequently in response to new evidence-based, peer-reviewed literature or technological advances. Developed by committees of academic and community practice specialists, the criteria are based on medical specialty society guidelines or appropriateness criteria, evidence-based medical reviews from AHRQ, CMS, the Cochrane library, the BlueCross BlueShield Technology Center, guidelines published by the National Government Clearinghouse, and others. These guidelines are supplemented with references to peer-reviewed literature. The criteria are also reviewed and approved by our clients’ medical policy committees.

We are not familiar with the details of the work flow for all RBMs, but CareCore National receives requests for prior authorization of high tech imaging services both by phone or web. Each request is compared to client specific published criteria, and, if medical necessity is demonstrated, an approval is immediately given to the requester. If the clinical information fails to demonstrate medical necessity, the provider and member are given an opportunity to submit additional information to support it.

If after review by a licensed physician, the request still fails to meet the criteria, a denial letter is sent to the requesting provider and the member. These letters are compliant with health plan, state, and federal requirements. They are written in easily understood language (no medical jargon or abbreviations) and contain specific patient-specific information as to why the service was not certified or was considered not medically necessary. CareCore National physicians are available to discuss requests with providers.

Our experience indicates that it is difficult for today’s busy practicing physicians to maintain a working knowledge of the enormous amount of ever-changing, evidence-based medicine and that having well-researched and well-vetted criteria available provides these physicians and their patients access to timely information and supporting literature. During the medical necessity review process, requesting providers are also educated with regard to the most current best practices for imaging.

RBMs have a responsibility to ensure that every individual covered by its programs has access to high quality, appropriate imaging at the appropriate time. They also have a responsibility to assure that patients are not exposed to any more radiation than necessary in order to provide the best medical care and assure the best outcomes. In addition, everyone has a responsibility in these difficult economic times to be sure that health care dollars are spent appropriately on care that will influence management decisions.

We believe that the process used by health plans and medical specialty benefit management companies is fair. Despite being transparent, physicians, patients, advocacy groups and others have not taken steps to understand these processes. It is likely that medical necessity reviews will be a mainstay for diagnostic imaging. It is also likely that theses reviews will be implemented for other medical procedures and tests. Therefore, it is important to understand the processes that impact health care.

Shelley N. Weiner, MD, FACR is executive vice president and chief medical officer of CareCore National, a health care solutions company providing management services for radiology, cardiology, medical oncology, radiation therapy, musculoskeletal care, sleep care, and lab. She is board-certified in diagnostic radiology and is certified by the American Board of Quality Assurance and Utilization Review Physicians.