Insurers Hire Radiology Benefits Managers To Ensure Physicians Use High-Cost Scanning Technology Appropriately

Main Category: Health Insurance / Medical Insurance
Also Included In: Primary Care / General Practice;  Radiology / Nuclear Medicine
Article Date: 07 Nov 2008 - 7:00 PST

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Health insurers increasingly are hiring radiology benefits managers to hold down costs and ensure physicians use high-tech imaging tests only when there is a clear benefit for the patient, the Wall Street Journal reports. According to the Journal, the costs of such scans -- including MRIs and PET and CT scans -- "have helped drive up health care costs in recent years." CT and MRI scans have increased by 43% in five years to a total of 96.2 million procedures in 2007, while PET scans have more than tripled from 2001 to 2005, for an estimated total of 1.1 million, according to the market research firm IMV Medical Information Division.

A recent Government Accountability Office report found that Medicare spending on scans varied significantly by geographic region and suggested that not all procedures were "necessary or appropriate." According to the Journal, other research shows that a "substantial portion" of scans are ordered by physicians with a financial stake in the equipment being used, which would qualify as a conflict of interest. Physicians also might order unnecessary tests to protect themselves from liability, the Journal reports.

John Jesser, a vice president for health care management at WellPoint, said, "There's a lot of new technology, and it's emerging faster than physicians' knowledge" of how to use it. He said an RBM can provide up-to-date research on when an imaging scan is necessary. RBMs say their guidelines are based on scientific evidence and medical groups' recommendations, and the companies often require physicians to obtain permission for ordering a scan before an insurer will cover it.

Robert LaGalia, president of National Imaging Associates, estimates that about 90 million consumers are enrolled in health plans that use RBMs, which accounts for more than half of all U.S. residents with private insurance. The three largest RBMs -- CareCore National; American Imaging Management, a WellPoint subsidiary; and National Imaging Associates, a unit of health care managing firm Magellan Health Services -- say they generally grant immediate approval to 70% or more of imaging requests and authorize even more after having in-depth conversations with doctors.

However, according to the Journal, some physicians say RBM reviews can "result in delays or rejections that sometimes pose risks for patients." Doctors also say that the reviews "waste their staffs' time and force physicians to justify decisions to reviewers who haven't seen their patients," the Journal reports (Wilde Mathews, Wall Street Journal, 11/6).

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