MRIs for aching backs and CT scans for headaches might be ordered by doctors a little less frequently this year.
Beginning in March, Blue Cross Blue Shield of Nebraska will ratchet up its scrutiny of certain diagnostic scans. Doctors ordering nonemergency, outpatient MRIs, CT scans and two other kinds of diagnostic imaging must first contact a Chicago firm to review them.
Blue Cross, the state’s largest health insurance provider, joins a growing group of insurance companies and states seeking tighter review of expensive diagnostic tests. The reviews are designed to contain costs and make sure the scans are necessary, although some worry that they are a step toward rationing care.
Nebraska’s Medicaid program has begun requiring prior approval for high-cost outpatient imaging. The State of Iowa’s Medicaid program will start to do so in March.
Wellmark Blue Cross Blue Shield in Iowa and South Dakota has contracted with the same Chicago company, American Imaging Management, for prior review of diagnostic imaging since 2005.
“It’s pretty common for insurers to do this,” said Rob Schweers, a spokeswoman for Wellmark in Des Moines.
Lee Handke, a Blue Cross Blue Shield of Nebraska vice president, said the use of high-tech medical imaging has grown substantially over the past 10 years, and insurers and others are concerned about overuse. Concern also has grown that repeated imaging, particularly with CT scans, has the potential to expose patients to too much radiation.
“It’s really a quality initiative, in our mind,” Handke said.
A report by America’s Health Insurance Plans estimated that from 2000 through 2008, use of imaging procedures increased close to 70 percent. Depending on the kind of scan and what it’s used for, the imaging can cost anywhere from a few hundred to a few thousand dollars.
Handke said Blue Cross in Nebraska won’t reject a doctor’s order, even if AIM deems it unnecessary.
But the process may compel the physician to think harder about whether a scan is necessary and, in some cases, to discuss scan guidelines with an AIM professional. The AIM guidelines are based on those established by medical organizations such as the American College of Radiology.
Handke said his firm eventually will review AIM’s results and determine whether it would be more appropriate to make denial a possibility.
A doctor’s staff submits an order to the Chicago firm by phone or computer, at which point a technician typically approves it. If further information is required, the doctor’s staffer will talk to an AIM nurse, and if approval still isn’t granted, the ordering physician will talk to an AIM physician. AIM executives said approval ultimately is given more than 90 percent of the time. The turnaround time typically is minutes, they said, but approval can take 24 hours.
Paul Danao, an AIM vice president, said the use of scans typically drops 15 to 25 percent after AIM is hired. The firm provides such reviews for insurance plans in 33 states.
Dr. David Soffa, AIM’s senior vice president for medical affairs, said the process helps some doctors resist patient demands for unnecessary scans and better understand professional guidelines for scans.
Soffa said doctors sometimes order an MRI after a patient bends over, strains his back and suffers severe pain. But 90 percent of the time, the problem goes away with the help of rest, medication and physical therapy, he said, so an MRI is unnecessary.
“Basically, our program is about increased physician awareness and education,” Soffa said.
Dr. Harris Frankel, a neurologist and past president of the Metropolitan Omaha Medical Society, said some people view such initiatives as denying or rationing care.
But diagnostic imaging has been the source of “out-of-control spiraling of costs over the last several years,” Frankel said. Most doctors order scans for the right reasons, he said, but some do it to avoid lawsuits or because they have a hard time telling patients the scans aren’t necessary. He said, however, that if almost all orders for scans are approved, it’s not clear that spending on unnecessary scans will decrease.
Unlike the Blue Cross program in Nebraska, AIM can deny a scan in Wellmark’s prior approval program in Iowa and South Dakota.
Blue Cross Blue Shield is far from the only insurer performing stricter reviews of scans. United HealthCare has programs in more than 30 states that have an in-house “mandatory notification process,” in which a doctor must inform insurance representatives that he is ordering a high-cost scan.
Although there is no approval required in that process, it prompts consideration about whether the scan is necessary, United says. The mandatory notification program isn’t used by United HealthCare in Nebraska or Iowa, a United spokesman said.
Blue Cross in Nebraska has required pre-authorization in certain cases such as orders for minimally invasive virtual colonoscopies, Handke said, and will continue to do so. Blue Cross contracts with physicians to review those cases and doesn’t use AIM.
Contact the writer:
444-1123, rick.ruggles@owh.com
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