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Health Insurers Create A New System To Limit Access To Expensive Radiology Tests

I just got notice from Blue Cross that they will be implementing a radiology management program for all advanced diagnostic imaging services starting in 2010.  The costs of advanced diagnostic imaging (such as CT, MRI, cardiac nuclear medicine) are rising 10-20% per year.

Radiology management companies are an attempt by insurance companies to slow that growth curve. What does that mean if you are a doctor?  Let me tell you how the program will operate.  Blue Cross calls it their Radiology Quality Initiative or RQI, not to be confused with PQRI.  Here are the details of their radiology benefit management initiative.

Q:  What are the requirements?

A:  All physicians ordering advanced imaging must contact the radiology management company to obtain an order number before scheduling elective outpatient high tech diagnostic imaging services.  The radiology imaging center should verify they have a number prior to service delivery.  Radiology imaging centers cannot obtain the order on behalf of the ordering physician.

Q:  What diagnostic imaging exams are included in this radiology management program?

A:  Outpatient elective CT scans, MRI, MRA, MRM, MRS, PET, fMRI, and nuclear cardiology studies

Q:  What types of exams are excluded in this radiology management program?

A:  All imaging services provided in conjunction with emergency room visits, inpatient hospitalization, outpatient surgeries, or 23-hour observation hospital stays.  These types of diagnostic imaging studies do not require an order number.

Q:  How does the physician obtain an order number from their radiology management company?

A:  There are two ways.  They can either register at the radiology management company’s website and follow the online process to request an order number or they can call the provided number.

Q:  What information is not required when submitting a request for an order number from the radiology management company?

A:  CPT or diagnosis codes are not required.  No records need to be faxed.

Q:  How does the program work in practice?

A:  The ordering physician office submits an order request through the radiology management’s internet application or through the call center.  The provider’s office will then be guided through an interview process where the member and ordering physician information, diagnosis, symptoms, exam type, and treatment/clinical history is requested.  If the information provided meets the radiology management  clinical criteria and is consistent with Blue Cross medical policy, the physician will then be guided to select an imaging provider where the imaging study will be performed and an order number will be issued.  If all criteria are not met and additional information or  review is needed, the case is forwarded to a Registered Nurse (RN) who uses additional clinical experience and knowledge to evaluate the request against clinical guidelines.  The nurse reviewer has the authority to issue order numbers in the event that he or she is able to ensure that the request is consistent the with the radiology management company’s clinical criteria and Blue Cross policy, when applicable.  If an order number still cannot be issued by the nurse reviewer, the case is forwarded to a Physician Reviewer (MD), who contacts the ordering physician directly to discuss the case and diagnostic imaging guidelines prior to issuing the order number.  The physician reviewer will issue an order number based on a review of information collected and or through discussion with the ordering physician.  If the request does not meet the radiology management company’s clinical guidelines, the request will be recorded as having received an order number without meeting clinical criteria.

Q:  How long is the order number valid?

A:  60 days.

Wow.  I don’t know where to begin. Obama promises everyone will have insurance.  How long can this madness last before doctors give up?  I have no idea.  The 60 day  requirement is interesting to me as a hospitalist.  I often have follow up CT scans ordered for three to six months down the road to follow up a small pulmonary nodule or adrenal mass.  According to Blue Cross, I would have to call the radiology suite 30 days after my patient is discharged and schedule the CT scan.  That ain’t gonna happen.  Not in a million years.

What about those folks who need a follow up scan within  60 days? For example, what about the  diverticulitis patient with an abscess that needs a follow up CT scan in 2-4 weeks?   I don’t even know what insurance my patient has, let alone what radiology management portal to log in to or what radiology center the patient will use as an outpatient.  If my patient needs preauthorization for an outpatient scan that I am ordering in the next 60 days, either the floor clerk will be trained to do it, or the patient’s primary care doctor is going to arrange it.  I’m going to stay out of that loop.

I called Blue Cross and spoke with a nice lady who made it sound like the program was a wonderful addition to patient care.  I asked her if they had plans in place to remove doctors who show a pattern of clinical compliance.  Nope.  No plan.  I asked her if they had data suggesting what percentage of doctors were prescribing advanced radiology imaging that didn’t follow clinical guidelines.  She had no idea.  I asked her how much money they expected to save.  Not a clue.

In fact, this effort to save money will do what PQRI has done.  Nothing.  It nibbles at the edges while the train full of health care dollars plows full speed ahead.  Stop nibbling at a broken system and change how you play the game.  The reason doctors order so many radiology tests is not because they don’t know what they are doing.  They know very well what they are doing.  They order lots of radiology tests because they don’t have time to cogitate because you pay so poorly for your cogitative services.  Doctors order a lot of radiology tests because they don’t want to be charged with negligence in a failure to diagnose suit.  They order a lot of tests because patients demand answers in this Me and Now world we live in.

Doctors don’t order a lot of radiology tests so they can subject themselves to obstructive radiology management corporations.

I’m not going to play these games.  At some point, either the insurance companies will have to start paying more money for the overhead and time commitment given to doctors through  their cost control measures or the patient will have to spend their time with preauthorizing their own scans.

The big question is when will physicians just stop and say no.  When will they walk away from the headaches imposed by third party medicine?  With this additional obstruction imposed by radiology management companies, I for one am glad I’m a hospitalist where all I get to do is practice medicine.  It’s also another reason how bundled care initiatives would remove the administrative burden from the backs of doctors just trying to do the right thing.

*This blog post was originally published at The Happy Hospitalist Blog*

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