Radiology Workflow Solutions Help Reduce Imaging Expenses


Radiology workflow solutions eliminate insurance claim inaccuraciesWell-designed radiology workflow solutions eliminate inaccuracies preceding data reporting, leading to a reduction in claim denial follow-up. Claim denial has come to the forefront as health insurance plans have implemented broad-based utilization management systems whose process includes denial provisions. In an effort to control medical imaging costs, health plans may (and have) refused to pay for requested studies that have been performed.

Radiology workflow solutions automatically alert radiologists of all new exams that require custom protocoling based on a health plan’s denial provisions. Yet, according to a study recently published in the Journal of the American College of Radiology, the removal of these denial provisions in utilization management for advanced diagnostic imaging won’t result in increased imaging.

Study Claims Denial Provisions Don’t Reduce Use

The results of the study are in stark contrast with the opinion that denial provisions—which refuse payment for studies not considered appropriate by the preauthorization system—reduce use, and that allowing physicians to order exams not endorsed by the system would lead to utilization growth.

“A collaborative utilization management system that does not deny payment, interfere with the doctor-patient relationship, or force test substitution could reduce the friction associated with utilization management without necessarily increasing expenditures on imaging,” wrote Jeffrey D. Robinson, MD, of University of Washington, Seattle, and colleagues, and authors of the study.

According to Health Imaging, results of the study were based on a retrospective review of records from HealthHelp, a national imaging utilization management company that works with health insurance plans. The company’s process is similar to other radiology benefits management systems in that it sets rules for which exams are considered appropriate based on indications and suggests alternatives, if a requested study doesn’t meet guidelines. However, unlike other systems there is no denial provision, and a provider may go ahead with a request that isn’t indicated, explained Robinson, et. al.

The researchers looked at a health plan that used a no-denial pre-authorization system for CT, MRI, PET and nuclear cardiac imaging in all but four of its geographic markets, which became the experimental group. They retrospectively reviewed 247,117 advanced imaging requests 21 months before and 16 months after the elimination of the denial provision in the experimental group.

Compared with matched control markets, in which a collaborative model was in use for the entire study period, the utilization growth rate in the experiment group decreased slightly by 0.10 requests per 1,000 covered lives, reported the authors. Approval rates were unchanged.

Robinson and colleagues suggested that the educational process provided by the authorization consultations countered the natural tendency of people to take what they can get, even if at the end of the process an imaging request is granted regardless of its appropriateness based on guidelines.

Collaborative Consultation Needed

The researchers hypothesized that a collaborative consultation between a radiologist and ordering physician–without the threat of denial of payment—would not result in higher imaging utilization. They believe that an educational process that requires an imaging professional to provide a rationale for appropriate imaging “would counterbalance the natural tendency of people to get as much as they can until someone says, “No.”

Accurately capturing medical coded data with a radiology workflow solution is vital to ensure that radiology departments receive optimum reimbursement and collect comprehensive benchmarking data to help improve clinical and financial decision making, facilitate health policy approvals and track patient trends.

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