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Report: Most Imaging Insurance Denials Due to Prior Authorization


Just over 90 percent of imaging case denials were for imaging services covered by the plan, a patient advocate report finds.

A vast majority of insurance denials for imaging exams were due to prior authorization programs, according to a new report. Further, just over 90 percent of denials for imaging exams were for services covered by the insurance plans.

The report was produced by the nonprofit Patient Advocate Foundation, which provides case management services to Americans with chronic conditions, and the Medical Imaging and Technology Alliance’s Advocacy Research Working Group. It analyzed PAF patient data on imaging access from 4,360 reports between June 1, 2007 and June 30, 2011.

The report points to prior authorization programs as the culprit for 81 percent of the insurance denials for imaging procedures, which stated reasons such as “not medically necessary,” “benefit exclusion” and “necessary prior authorization needed to be obtained.”

“Health care decisions should be made by physicians and their patients, not by an intermediary whose top priority is cost-cutting and who does not provide transparency in their decision-making to the patient or physician,” Gail Rodriguez, executive director of MITA, said in a statement. “Instead, policymakers should embrace evidence-based, physician-developed appropriateness criteria to guide the proper use of imaging services.”

PAF also found that, on average, its professional case managers had to contact the insurer more than 15 times before reaching a resolution, according to the report.

MITA said the report shows prior authorization programs “obstruct patient access to necessary or medically appropriate diagnostic imaging services and reduce the transparency behind coverage decisions.” The group urged Congress to instead pursue appropriateness criteria to manage imaging utilization.

The Access to Medical Imaging Coalition also applauded the report, noting there has been no scientific research on the safety or impact on costs of radiology benefit managers. AMIC reviews have found prior authorization policies could cost insurers and the government more money than they save.

“The PAF study demonstrates that prior authorization within a health insurance program is obstructive to patients’ access to care, and independent reports suggest time and again that it would be equally ineffective in Medicare,” Tim Trysla, executive director of AMIC, said in a statement. “Unfortunately, in spite of the data, the Obama administration’s proposed 2013 budget does include prior authorization for medical imaging in the Medicare program, severely impeding access to vital medical imaging and diagnostic services among seniors - our nation’s most vulnerable population."

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