Insurers Hire Radiology Police to Vet Scanning

Firms Make Doctors Justify Costly CTs, MRIs and PETs; Patients 'Stuck in the Middle'

The Wall Street Journal

By ANNA WILDE MATHEWS

Thursday, November 6, 2008

 

Health insurers are increasingly relying on outside firms to help rein in the skyrocketing costs of imaging scans like MRIs. But when these middlemen clash with doctors about what tests are needed, consumers can get caught in the crossfire.

Big insurers including Aetna Inc., WellPoint Inc. and Cigna Corp. have hired so-called radiology benefits managers, or RBMs. Health plans say they want to ensure that doctors use high-tech scans only when it is clear that patients will benefit. The RBMs say their guidelines are based on scientific evidence and medical groups' recommendations. Often, the firms require doctors to get permission to do a scan before the insurer will agree to pay for it.

"There's a lot of new technology, and it's emerging faster than physicians' knowledge" of how to use it, says John Jesser, a vice president for health-care management at WellPoint. An RBM can offer the most up-to-date, best-researched information on when to perform an imaging scan, he says.

Some doctors say the RBMs' review procedures can result in delays or rejections that sometimes pose risks for patients. Doctors also complain that the procedures waste their staffs' time and force physicians to justify decisions to reviewers who haven't seen their patients.

Leslie Hammer, a 46-year-old homemaker in Darien, Conn., says she felt "stuck in the middle" after her insurer and its outside RBM denied coverage for a breast MRI that her surgeon, oncologist and radiologist had recommended. Ms. Hammer, who had breast cancer in 2005, ended up paying for the scan herself. "If it comes back, I definitely want to find it in the earliest stage possible," she says.

UnitedHealth Group Inc., the parent of Ms. Hammer's insurer Oxford Health Plans, said an MRI wasn't medically necessary, a view upheld in an outside review by a New York state regulator. The company said the American Society of Clinical Oncology recommends against MRI in women like Ms. Hammer "with a personal history of disease who are treated for cure and are now in surveillance." An official with the RBM, CareCore National LLC, said its criteria are consistent with national guidelines.

Related Links

Here are some online resources to learn more about imaging scans and radiology benefit managers:

        General background about imaging scans: radiologyinfo.org, myradiologist.com

        A searchable list of facilities that have been accredited by the American College of Radiology

        Guidelines from some medical groups laying out when scans are appropriate for certain conditions: Acr.org, Onlinejacc.org, amcanceroc.org

        Similar guidelines from some big benefit managers: www.americanimaging.net, carecorenational.com, radmd.com

        A calculator from a benefit manager highlighting radiation doses from imaging scans.

Scans have helped drive up health-care costs in recent years. The number of computed tomography, or CT, scans, and magnetic resonance imaging, or MRIs, increased 43% in five years to a combined 96.2 million procedures in 2007, according to IMV Medical Information Division Inc., a market-research firm. Positron emission tomography, or PET scans, more than tripled from 2001 to 2005 to an estimated 1.1 million.

Scanning costs depend in part on what's being examined. The American College of Radiology says Medicare's average reimbursement for a CT scan of the head, for instance, is $228.52, and for an MRI of the neck and spine, it's $977.31. The group says there is no national average for PET scans, but the price could easily top $2,000. Private insurers typically pay more than the government.

Edward Agura, an oncologist at Baylor University Medical Center, wanted to monitor a patient, Dallas resident S. Blaine Porter, with PET scans every three months for two years after Mr. Porter, 47, was treated for aggressive lymphoma in 2006. Dr. Agura and Mr. Porter say RBM American Imaging Management and Mr. Porter's insurer, Blue Cross and Blue Shield of Texas, a unit of Health Care Service Corp., required pre-approval for each scan, which delayed the tests. As a result, they say, Mr. Porter waited around four months or more between PETs. In July 2007, Mr. Porter had a seizure that turned out to be caused by a new tumor, this one between the two lobes of his brain.

Dr. Agura says he believes that the new brain tumor might have been detected earlier if the scans had taken place promptly every three months. "Every time we scanned him, we had to go through a lengthy approval process," he says. "Delays in approval lead to cancers coming back and not being detected."

Imaging Problems

More health insurers are relying on outside firms to manage requests for imaging scans.

                Reviews are meant to weed out unnecessary scanning procedures.

                Doctors say denial of a request can pose risks for some patients.

                If coverage is refused, doctors and patients can appeal.

In a statement, Blue Cross and Blue Shield of Texas says it didn't deny requests for Mr. Porter's PET scans, and it found "no evidence that processing delays ... compromised the member's health or medical condition." The insurer said that in two cases, it responded to requests within four to seven days, but then there was a wait before Mr. Porter actually got the scan. American Imaging says it can't comment on specific cases, but it generally processes reviews promptly.

Radiology-benefits managers date back around two decades, but the industry's growth has accelerated in recent years. The three biggest RBMs are CareCore National; American Imaging Management, a WellPoint subsidiary; and National Imaging Associates, a unit of Magellan Health Services Inc., a health-care management firm.

Robert LaGalia, president of National Imaging Associates, estimates that around 90 million consumers are now covered by RBMs. That represents more than half of all Americans who have private insurance. Mr. LaGalia says before the insurers employed RBMs they often did without imaging-review programs, or only exerted limited oversight of scans.

There is evidence that a significant number of scans ordered by doctors aren't needed. A recent Government Accountability Office report noted that Medicare spending on scans varied sharply by geographic region, suggesting that the procedures weren't all "necessary or appropriate." Other research has shown that a substantial portion of imaging tests are ordered by doctors who have a financial stake in the imaging equipment being used, a potential conflict of interest. Physicians may also order imaging tests that aren't always necessary to protect themselves from liability. Excessive use of scans is a particular worry with CT, because it can expose people to high doses of radiation.

The three big RBMs say they generally give ready approval to 70% or more of doctors' requests for scans, after the physician's office provides some basic information. Still more scans get authorized after doctors have in-depth conversations with RBM representatives, the companies say.

Here are some pointers to help consumers navigate the radiology-benefit model.

If your doctor does recommend a scan, you may want to check whether you fit professional guidelines from medical groups such as the American College of Radiology and the American Cancer Society. You also can avoid duplicate scans by telling your doctor when you've already had a test, and bring copies of earlier exams to your appointments.

If your scan is approved by a contractor, you might still want to double-check with your insurer. Doctors say they periodically see snafus like the one that happened to Edward Latham, an architectural consultant from La Grange, Ill.

Mr. Latham got a heart CT scan after he was told by his cardiologist's office that American Imaging had preauthorized the test. Later he was billed nearly $1,900 by his insurer, Blue Cross and Blue Shield of Illinois, a unit of Health Care Service. The cardiologist's office appealed and was denied. Eventually, the practice, which owned the scanning equipment, wrote off the cost of Mr. Latham's test.

After reviewing Mr. Latham's situation to respond to questions from a reporter, Blue Cross and Blue Shield said in a statement that American Imaging had preauthorized the scan but that the insurer had billed the patient "in error."

"It was eye-opening to me to realize there's this whole bureaucracy in place," Mr. Latham says.

Patients should check whether an imaging facility is accredited by a group like the American College of Radiology or the Intersociety Accreditation Commission, either by asking or checking the ACR's Web site. Depending on your out-of-pocket payment for scans, you may also want to ask about pricing, which can vary widely. Some insurers, including Cigna and WellPoint, post pricing data on their Web sites for various facilities.

If your health plan or RBM denies coverage of your scan, you or your doctor can appeal. Typically, doctors can discuss the case with a staff physician at the RBM. And your insurer likely has a formal appeals process that you can use. If your appeal is rejected, you can often further appeal through a state process.

 

Write to Anna Wilde Mathews at anna.mathews@wsj.com