David Pike

MedSolutions – Benefits Management Programs Overview

What Are Radiology Benefits Management Programs?

Radiology benefits management (RBM) programs have been used by health insurance companies since the 1990s to assist in reducing the overuse of advanced imaging, which is the process of creating images of the human body for diagnosing clinical issues. While numerous imaging procedures can be categorized as advanced imaging, services typically included in an RBM program are computerized tomography (CT) scans, magnetic resonance imaging (MRI), and positron emission tomography (PET).

Health insurance companies that implement an RBM program require providers to submit requests for their members to receive advanced imaging prior to conducting procedures. Decisions are determined using evidence-based guidelines created through industry standards, published literature, and reviews conducted by qualified clinical experts. Most RBMs also support the prior authorization process with clinical staff experienced in radiology who offer providers additional resources to assist with their advanced imaging requests.

RBMs are already successfully used by numerous commercial health insurance companies, including Aetna, CIGNA, UnitedHealth, and Humana, as well as several state Medicaid programs. According to an article published in the Radiology Business Journal in July 2009, it is estimated that RBMs cover approximately 100 million to 130 million health insurance members in the United States and have saved health insurance companies hundreds of millions of dollars.1

Why Are Radiology Benefits Management Programs Necessary?

America’s Health Insurance Plans (AHIP) has stated that diagnostic advanced imaging costs are reported to be the fastest growing component of medical technology, with spending approaching $100 billion annually. AHIP’s study shows that a range of 20% to 50% of advanced imaging fails to provide information that improves a patient’s diagnosis and treatment. AHIP also states that one-third of imaging procedures may be inappropriate.2

Several factors have contributed to the increase of advanced imaging procedures, including:

  • Use of services previously unavailable or difficult to access.
  • Adoption of emerging technologies without appropriate education on how they contribute to the clinical situation.
  • Quality issues resulting in the duplication of procedures due to the ineffectiveness of previous scans.
  • Rise in self-referrals, which is when a provider orders advanced imaging procedures for patients and either performs the procedure themselves or has the procedure completed at a facility from which they receive a financial incentive for the referral. One recent study stated that “once orthopedists and neurologists began acquiring their own MRI equipment in the early 2000s, their ordering of these tests increased 38%.”3 According to a 2002 article in the American Journal of Roentgenology, advanced imaging procedures “were ordered 22% to 52% more often by physicians with ownership interests in outside facilities than by others.”4
  • Defensive medicine practices, which occurs when physicians order procedures to protect against litigation in the event of an unfavorable outcome of treatment. According to one report, some estimates show that the practice of defensive medicine costs the United States healthcare system from $60 billion to $108 billion dollars annually.5 In a study presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons, researchers found that of the advanced imaging studies ordered by participating orthopedic providers, nearly 35% of all imaging costs were ordered for defensive purposes, including over 38% of MRIs and over 40% of CT scans. The study also reported that “physicians who had gone through litigation in the past five years reported a 63% greater incidence of defensive imaging than those who had not.”6

RBMs have proven they assist in the reduction of unnecessary overutilization of advanced imaging by requiring prior approval for requested procedures. This reduction results in significant benefits for patients, providers, and health insurance companies.

What Advantages Do Radiology Benefits Management Programs Offer?

Patients: RBMs ensure patients receive the correct test at the correct time in the diagnostic process. The RBM process identifies requested procedures that may be unnecessary or that can be dangerous to the patient’s health when a less harmful test can offer the same diagnostic benefits. Many patients are unaware of the health risks associated with advanced imaging procedures. According to a report published by the National Council on Radiation Protection and Measurements (NCRP), “in 2006, Americans were exposed to more than seven times as much ionizing radiation from medical procedures as was the case in the early 1980s.” The article states that this increase in exposure was primarily due to the growth in the use of medical imaging procedures.7 HealthLeaders Media stated in 2009 that “the National Cancer Institute estimates nearly 30,000 excess cancers occurred from the 72 million CT scans in the U.S. just in 2007.”8

Based on this information, by thoroughly evaluating a provider’s request and determining its appropriateness, RBMs help eliminate unnecessary radiation exposure, which reduces patient safety risks and future downstream healthcare issues and costs due to the harmful effects of advanced imaging.

Most RBMs also offer a quality component that evaluates a facility’s imaging staff and equipment to ensure procedures are being conducted appropriately. This quality process results in imaging being performed more accurately and within a provider’s expertise. A patient’s exposure to unnecessary radiation is avoided by eliminating the need for duplicate studies due to low quality scans.

Providers: Technology is constantly changing, and it is difficult for providers to be continuously educated on how those changes affect them and their patients. This issue is especially true for providers who do not routinely order advanced imaging procedures. RBMs help remove this burden from providers by providing them guidance on the most appropriate imaging to order based on technology advancements, as well as the patient’s history, presentation, and diagnostic needs.

Health Insurance Companies: By partnering with RBMs, health insurance companies provide their members with access to affordable services performed in quality facilities. Health insurance companies also cut significant, unnecessary cost from healthcare. According to an article in Managed Healthcare Executive, RBMs have been shown to decrease advanced imaging use “by 15% to 20% and reduce long-term growth trends by up to 50% and can do so with a denial rate of less than 3%.”9 Denial rates are low even with such high utilization decreases because in addition to ensuring the most appropriate procedure is approved, RBMs also have the effect of reducing unnecessary requests because providers are less likely to order inappropriately when they are being monitored. The article also states ordering providers have reported a 90% satisfaction rating when dealing with RBMs, which ensures that a health insurance company’s provider network will most likely be unaffected by the implementation of an RBM program.

1Wiley, George, “RBMs: The Debate Heats Up,” Radiology Business Journal (July 01, 2009): http://www.imagingbiz.com/articles/view/rbms-thedebate-heats-up/.
2“Ensuring Quality through Appropriate Use of Diagnostic Imaging,” AHIP (July 2008).
3Ken Terry, “How Self-Dealing Among Doctors Continues to Push Up Medical Costs,” CBS News (December 23, 2010): http://www.cbsnews.com/8301-505123_162-43842282/how-self-dealing-among-doctors-continues-to-push-up-medical-costs/?tag=bnetdomain.
4Brian E. Kouri, R. Gregory Parsons, and Hillel R. Alpert, “Physician Self-Referral for Diagnostic Imaging: Review of the Empiric Literature,” American Journal of Roentgenology (October 2002): http://www.ajronline.org/content/179/4/843.full.
5John Carroll, “Going on the Offensive against Defensive Medicine,” Managed Care Magazine: http://www.managedcaremag.com/archives/0503/0503.regulation.html.
6Press, Robert, “Study Finds Many Imaging Studies Performed for Defensive Purposes,” Orthopedics Today (April 2011): http://www.orthosupersite.com/view.aspx?rid=81784.
7NCRP Report No. 160, “Ionizing Radiation Exposure of the Population of the United States,” National Council on Radiation Protection and Measurements: http://www.ncrponline.org/Publications/Press_Releases/160press.html.
8­Clark, Cheryl, “The Five Best Things and Five Worst Things About Healthcare in 2009,” HealthLeaders Media (December 23, 2009): http://www.healthleadersmedia.com/page-2/LED-243951/The-Five-Best-Things-and-Five-Worst-Things-About-Healthcare-in-2009.
9Soffa, David, “Medicare Could Benefit from Radiology Management,” Managed Healthcare Executive (June 1, 2009): http://managedhealthcareexecutive.modernmedicine.com/mhe/Managed+Care+Outlook/Medicare-could-benefit-from-radiologymanagement/ArticleStandard/Article/detail/601161?contextCategoryId=2290.

 

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