Health plans are under increasing pressure to contain costs while providing high quality care. As they seek opportunities to increase efficiency, they would be prudent to consider the management of routine radiology claims.
While advanced images such as CT, MRI and PET are often subject to prior authorization (PA), routine radiology, including X -ray nuclear medicine, ultrasound and non -cardiac, they are generally not. Because it is more common and costs less per unit, routine tests are approved with little or no verification by plans as to whether they are consistent or following the best practices guidelines. This supervision presents a challenge and an opportunity for plans.
The United States spends about $ 100 billion annually in medical images, and studies suggest that 30% of this expense could be unnecessary. That is unnecessary financial drainage in an overloaded health system. In addition, unnecessary image exposes patients to avoidable radiation risks and unnecessary medical interventions.
In 2022, a review of the claims of a commercial health plan with 700,000 members revealed that around $ 389 per month (PMPM) were spent on medical images. Of this, around $ 137, or 35%, they get used to routine radiology. While these services have lower cost per unit than advanced images, their high volume makes them a significant expense. The analysis showed that approximately 8% of routine radiology statements were inconsistent with established care standards. Some frequent cases of WastFull practices include:
1. Preoperative thorax X-rays in healthy patients Guidelines discourage routine thorax radiographs before surgery for asymptomatic and healthy patients. Despite this standard of attention, thesis procedures are often ordered reflexively. In the data set, only approximately 8% of claims for chest radiographs were inconsistent with thesis patterns, offering a clear opportunity to reduce radiation and unnecessary costs.
2. Duplicate or redundant exams – Doctors can order complete and limited exams in the same area, for example, abdominal ultrasound or limb images, when the most complete examines the limited. In the sample data, approximately 7% of abdominal sounds were duplen or unnecessary.
3. Studies of excessive or bone age use – This test, used to evaluate skeletal maturity, should be reserved for specific pediatric indications and not perform more than once annually. However, in 14% or in revised cases, it was exaggerated or used without a clear indication.
The solution: automated policy -based claims management
Routine radiology management does not require the administrative burden of prior authorization. Instead, health plans can implement automated management after service and anticipated payment based on clinical guidelines. Here is like:
- APPLICATION OF AUTOMATED RULES – Claims are evaluated in real time against a set of routine radiology policies aligned with national standards and specific plan preferences.
- There is no delay to worry – Unlike the AP, this model does not delay patient care and does not hold members responsible for paying the not necessary exams.
- Improved supplier behavior – The denials are encoded as the responsibility of the supplier, promoting the adhesion of the guidelines through feedback instead of the interruption.
RUTINE RADIOLOGY MANAGEMENT BENEFITS
By helping to ensure that appropriate patients receive the correct diagnosis at the right time, routine radiology management can improve their results. Patients will also benefit from a reduced exposure to CAA radiation through unnecessary images and any risk raised by subsequent care results. Less evidence also less false positions that can lead to unnecessary attention and high costs. The members will not have to pay pocket costs for inappropriate care.
The automated management model also provides claims, reports and education decisions to suppliers that will be more likely to adhere to policy guidelines when ordering routine images.
The plans will benefit through high quality and high quality care with an estimated savings of up to $ 1 PMPM. In addition, the combined effect of these benefits will support Healthcare transition to value based on value.
Why routine radiology management is a good idea
As the pressures are mounted on the plans to control the expense and pocket expenses of the members, while simultaneously to improve the attention, it makes sense that they return to examine areas that have not been administered.
Given the volume of evidence and the high incidence of non -adherence to planned policies, routine radiology is one of those areas. An automated evidence -based approach is a simple and necessary step to control costs and improve attention.
Jim Koger, vice president of Avalon Healthcare Solutions, is an experienced health products manager dedicated to improving access to affordable care through the development of innovative solution management solutions. It emphasizes the importance of advancing in the diagnosis of routine within the areas of laboratory tests and radiology.
Mark Hiatt, MD, MBA, MS, consultant of Avalon Healthcare Solutions, is a trained radiologist in Stanford-Fellowship with career voltage leadership roles in a radiology department, health system, radiology benefit management firm. He has developed programs to guarantee the appropriation, quality and profitability of medical images and advise on the optimization of clinical validation and market access strategies. He defends evidence -based image management to support quality and sustainability.
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