Imaging services have already come under fire from the federal government: The GAO issued a report this summer calling attention to the fact that, from 2000 through 2006 Medicare spending for imaging services more than doubled, increasing to about $14 billion. At the beginning of November, the Department of Health and Human Services issued an Outpatient Prospective Payment System (OPPS) final rule that not only creates five imaging composite APCs that will provide a single APC payment when two or more imaging procedures using the same imaging modality are provided in a single hospital session, it also adopts four new quality measures for imaging efficiency.
Now, the WSJ reports on page D1 of its Nov. 6 edition, “Big insurers such as Aetna Inc., WellPoint Inc. and Cigna Corp. say they have hired so-called radiology-benefit managers, or RBMs, to ensure that doctors use high-tech scans only when it is clear that the patient will benefit. The RMBs say their guidelines are based on scientific evidence and medical groups’ recommendations. ”
The point of contention and frustration for many providers is that the insurers often require physicians to obtain an RBM’s permission before they will agree to reimburse for imaging services: “Some doctors say the RBMs’ review procedures can result in delays or rejections that sometimes pose risks for patients. Doctors also complain that the procedures waste their staffs’ time and force physicians to justify decisions to reviewers who haven’t seen their patients,” says the story.
The article goes on to recount bad experiences patients have had as a result of dealings with RBMs including one in which the early stages of a patient’s brain tumor went undetected because of a treatment delay. The patient’s insurer denies RBM-related delays were at fault. The report says that RBMs approve more than 70 percent of requests based on information sent along with the requests, and that more are approved when further evidence is presented.
Read the full text of Insurers Hire Radiology Police to Vet Scanning.
