Radiology Benefits Managers Provide Oversight to Excessive Imaging Tests

As tempting as it is to demonize health insurance companies for their constant focus on cost containment, when it comes to their use of “radiology benefits managers” the financial watch is actually a good thing. Many companies, including CIGNA, UnitedHealthCare and Wellpoint, use radiology benefits managers (RBMs) to determine whether imaging tests are really necessary. Some consumers may squawk that this limits access to tests they need to have, but I think it is important to acknowledge that medical imaging is a field that has been rife with abuse. Patients are vulnerable to unnecessary procedures and exposed to potentially carcinogenic levels of radiation and sometimes even end up misdiagnosed as a result of imaging they didn’t actually need. Hospitals and doctors may have a financial incentive to refer patients for costly imaging procedures, necessary or not — and really, without someone checking things out, who’d know?

BETTER CARE, LOWER COSTS

Diagnostic imaging, which includes CT (computed tomography), MRI (magnetic resonance imaging) and PET (positron emission tomography) scanning, is a multi-billion dollar a year industry in this country. Diagnostic imaging unquestionably saves lives when used appropriately, but unfortunately it is over-utilized. A report by America’s Health Insurance Plans in July 2008 states that imaging procedures grew about 40% from 2000 to 2005. According to the report, “estimates suggest that a full third of imaging procedures are inappropriate,” at an annual cost between $3 billion and $10 billion.

A Government Accountability Office (www.gao.gov) report notes that Medicare spending on imaging varies widely from region to region across the country and suggests that “not all utilization was necessary or appropriate.” An example: In 2006, in-office imaging spending ranged from $62 per Medicare patient in Vermont to $472 per Medicare patient in Florida. Many medical practices have their own scanners — the more scans they do, the more money they make.

Yet another factor may be the need for physicians to practice “defensive medicine” and order tests primarily to protect themselves from liability. It’s a real concern, cautions patient advocate and newspaper columnist Trisha Torrey (EveryPatientsAdvocate.com). In the event they are sued for missing a diagnosis or making a wrong one, a physician needs to be able to show that all bases were covered. The result, however, can be unnecessary scans that expose patients to dangerous radiation.

Enter radiology benefits managers. Radiology benefits managers are essentially gatekeepers of imaging services, whose goal it is to reduce the volume of unnecessary procedures and, in turn, unnecessarily high costs to insurance companies. Some people complain that denial of reimbursement for high-tech scans delays diagnoses and puts patients’ health at risk. They also worry that erecting another barrier to health care forces medical practice personnel to waste hours wrangling with bureaucrats to justify their decisions.

SERIOUS CONCERNS ABOUT OVERUSE

Studies cast doubt on whether there is an overall medical benefit from this explosion in high-tech imaging. In research presented at the 75th Annual Meeting of the American Academy of Orthopaedic Surgeons in 2008, doctors noted that simple and inexpensive X-rays are better for diagnosing arthritic knees than MRIs — while in a random review of the records of 50 knee replacement patients, they found that 32 underwent MRIs that provided no more useful diagnostic information than X-rays. The authors pointed out that X-rays cost on average less than $150 while the tab for an MRI can be $2,500.

There are other issues, too. For example, MRIs can be problematic when used to diagnose back pain, which they often are. After age 50, practically everyone has some abnormalities of the lumbar spine but often it’s not a problem. However, when a doctor sees such an abnormality on a scan, it may be quickly identified as the reason for pain that may, in fact, not be related at all. Surgery may be recommended that is not only unnecessary, but ends up leading to yet more pain. According to a study in the February 2009 issue of the Journal of the American Academy of Orthopaedic Surgeons, most people with lower back pain recover within three months even without treatment.

HOW TO COPE WITH
RADIOLOGY BENEFITS MANAGERS

Assuming that the current use of diagnostic imaging is flawed, are RBMs the right solution? I’m sure it depends… but like it or not, radiology benefit managers are here to stay. Insurers have employed radiology benefits managers for over a decade, and as the volume and cost of imaging tests grows, their ranks continue to swell.

Most Americans covered by private insurance must now receive prior authorization before undergoing an imaging test. Here are some tips on how to manage your own care in this brave new world…

  • If your doctor recommends an imaging test, ask why and read about medical appropriateness for it on the Web site of the American College of Radiology (www.acr.org/ac).
  • Double-check with your doctor to make sure the imaging procedure is really necessary to obtain information that can improve your outcome.
  • If prior authorization of your scan is denied and you and your doctor believe it is vital, ask your doctor to consult further with the RBM or a staff physician at the insurance company. If this fails, insurers have formal processes for doctors and patients to follow.
  • Even if your scan is approved, it’s best to double-check directly with your insurer about coverage for it. Mix-ups are known to occur — and you don’t want to get stuck with a bill your insurer refuses to pay.
  • For quality assurance, check to see that the recommended imaging facility is accredited by the American College of Radiology.

RBMs represent an interesting ethical challenge. There’s no doubt that some — maybe many — scans are necessary and provide benefit. On the flip side, I have watched as my aging parents get scanned and tested every time they get a virus… the test results add nothing to the diagnosis, yet their doctors continue to order more tests. RBMs are an attempt to bring some kind of rational control to an out-of-control process. Imperfect as it may be, it’s a step in the right direction.