Radiology Benefits Management (RBM)

technology trendRapid technological advances with enhanced clinical application have promoted the utility as well the growth of diagnostic imaging. With radiology costs in the United States growing to more than $100 billion annually, diagnostic imaging is the second-largest and fastest-growing expense for health plans behind pharmaceuticals. Factors driving this growth include fragmentation of care, the continual advances in diagnostic imaging technology, direct advertising to patients, and an aging population.

According to the Medicare Payment Advisory Commission's (MedPAC) March, 2015 annual report to Congress, imaging volume between 2000 and 2009 increased by 85 percent. This growth was more than double the cumulative growth of evaluation and management services and major procedures. While imaging volume has decreased by 7 percent since 2009, the use of imaging services has remained much higher than it was a decade ago, according to the report. Meanwhile, physicians and others continue to raise concerns about overuse of imaging, including the exposure to radiation that can accompany that overuse. Some physician organizations have responded to these concerns. Adverse effects due to the overuse of imaging is among the most frequently cited items in the Choosing Wisely campaign, the initiative of the ABIM Foundation to reduce wasteful tests and procedures across medical specialties.

Care to Care has developed programs and products designed to provide medically appropriate criteria for radiology utilization management. Our goal is to help physicians to be guardians of responsible health care by providing high-quality and appropriate imaging, but with fiscal responsibility. Care to Care contracts with insurers, payors and self-insured groups to manage the radiology benefits they provide to their members or enrollees. Each client health plan defines the range of covered services including coverage for experimental or investigational services. The need to ensure the most appropriate diagnostic modality is used is based on consideration of many factors including exposure to ionizing radiation, possible false positives leading to unnecessary interventions, and waste of scarce resources. In order to achieve reduced inappropriate imaging, American board certified radiologists developed Care To Care’s proprietary evidenced based clinical criteria. These criteria are used to ascertain the appropriate modality has been selected for the clinical situation presented. Cases that do not meet the assigned clinical criteria are sent to a board certified radiologist or nuclear cardiologist for evaluation and a possible peer to peer review with the referring physician

Care to Care’s advanced imaging utilization program can be applied to magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computerized tomography (CT), computed tomography angiography (CTA), positron emission tomography (PET), Nuclear Cardiology, and ultrasound. Services are provided by phone, fax, and web portal. Referring providers choose a method to submit prior authorization requests for services. Clinical information obtained will be evaluated with Care to Care proprietary evidenced based guidelines. If the request does not meet criteria for approval Care to Care will fax and call for additional information. A board certified radiologist or cardiologist (to review cardiology requests) will review the information and engage in a collegial conversation with the referring provider to educate when necessary.

Our rules of engagement are:

Limited administrative burden, with clinical information collection limited to the minimum required to render an opinion.

Referring physicians are educated as to the type and amount of clinical information that should be provided in a prior-authorization request. Timely and clear responses are provided to avoid delays in diagnosis, with respect for the time of the referring physician

Disclosure of details and source of utilization management process an evidence-based guidelines.

The utilization management process is transparent and evidence-based. The policies and procedures used in utilization management are available to the medical community and the public at large.

Evidence-based guidelines that are not restrictive to the delivery of patient care.

Solutions Our peer review process does not impose restrictive regulatory guidelines that interfere with the process of care and undermine the ability of physicians to individualize patient care.

Availability of nurses and fellowship-trained radiologists with extensive training of imaging modalities.

Efficient and timely prior-authorization is provided by radiologists with demonstrated ability and experience in a patient care environment.

Medical criteria for prior-authorization decisions are applied consistently across similar clinical situations.

Predictability in the prior-authorization process will promote compliance, help mitigate burdensome administrative cost and promote the delivery of a uniform quality of patient care.

Accreditation of imaging equipment and radiologists is provided.

Facilities with high-technology imaging equipment are required to be accredited by the ACR or equivalent organizations. These accreditation requirements include standards applicable to the physicians who provide the interpretations of the high-tech imaging studies.

Availability of electronic submission of requests to perform high-tech imaging studies.

The ordering physician can enter the patient’s clinical information and requested study and receive timely approval. Web-based prior-authorization processes facilitate the ordering of appropriate studies, improve compliance, assure process consistency, and lower the administrative costs.