Can Decision Support Supplant Precertification?

Health-care reform is here, and it’s the DRA all over again (but on steroids). Adjustments to the RVU for equipment utilization have increased from 50% to 62.5% for 2010 and will be capped at 75% for 2011 (for MRI and CT only). On July 1, the reduction in CT, MRI, and ultrasound technical-component reimbursement for contiguous imaging increased from 25% to 50%. Many commercial payors have already adopted the contiguous-procedure reduction or will do so soon.

Some commercial payors are now applying this reduction to the professional component within the global payment, and a few have started to apply it to the professional component alone. Blue Cross Blue Shield of Massachusetts, for example, has announced that it will implement a 50% reduction to the global and professional components in August 2010. The radiology professional societies are fighting hard to prevent this, but they don’t seem to be making much headway.

Payors are implementing higher deductibles and copayments, and radiology benefit management (RBM) companies are steering patients to providers of less-expensive (but not necessarily better-quality) imaging. About 70% of all covered lives in the United States are affected by the RBM process.

According to one RBM, the overall denial rate (including orders withdrawn, ignored, or changed) is about 4%, but other RBMs report denial rates as high as 10%.¹ Is the physician actually being educated by RBMs on the appropriateness of ordering high-tech imaging? Imaging centers and hospitals are finding ways around the RBMs to obtain precertifications for their referral bases, thereby creating a competitive edge for themselves. Is this all defeating the purpose of RBMs?

Decision Support

An alternative to the RBM model is clinical decision support, which is gaining broad interest. Hospitals, in particular, seem eager to find a method that will letthem reduce the effects of preauthorization and precertification on their costs.

One of the three leading decision-support systems in use today was developed by physicians at Massachusetts General Hospital (MGH) in Boston.²,³ For the MGH system, clinical information provided at the time of ordering is combined with the patient’s age to produce a utility score for the examination requested. The scores are derived from ACR® appropriateness criteria and from evidence-based medicine, and the scoring criteria are frequently reviewed by imaging and clinical experts.

A high utility score indicates that the clinical information provided strongly supports the use of the imaging test requested. A low score indicates that the information provided does not support the use of that test. The ordering physician will be asked to review the indications and to change, drop, or provide a reason to proceed with the order.

Beyond educating referring physicians on the appropriateness of high-tech exams, the system lets them see prior procedures ordered, preventing procedure duplication. Another anticipated feature of this system is physician notification, at the time of exam ordering, of radiation-dose concerns. Most important, the imaging-appropriateness criteria remain under the influence of the radiologists who are the clinical experts.

Decision support’s recommendations are made using a transparent algorithm (this is not the case for RBM recommendations). Decision support offers imaging alternatives, while RBMs do not. In addition, decision support can easily be integrated into major electronic medical record (EMR) systems.

Payors substituting decision support for RBMs will obviously save the RBM fee. In addition, hospitals can negotiate pay for-performance contracts with payors in which the hospital assumes some risk, making decision support a more attractive proposition for payors.

Promoting Adoption

It would be highly detrimental to radiology if CMS were eventually to adopt an RBM model. Administrative costs would continue to increase for the radiology provider and the referring physician. Many radiology professional societies are on board in favor of decision support, and several of them have issued position papers indicating this.

So far, decision support has gained payors’ acceptance slowly, perhaps because payors are unwilling to make changes to an RBM model that often works in their favor. This could change, however, as incentives for the meaningful use of health IT (and penalties for failure to show meaningful use) take effect. Decision support could qualify as meaningful use, leading more hospitals to adopt it; as they do so, they add to the reasons for payors to accept it, since dealing with two models for utilization management simultaneously would be expensive.

In June 2009, the Imaging e-Ordering Coalition was founded to promote decision support over the RBM model, as well as to promote the inclusion of decision support in EMRs and in public policy. Nonetheless, we want to continue to open channels to all RBMs, and we invite them to the table.

Christie James, MS, is lead radiology billing manager for the professional billing office of Massachusetts General Physicians Organization in Boston and is chair of the Payor Relations Committee of the RBMA. This article has been adapted from “Decision Support:Is It an Alternative t oRBMs?”(which she presented to the Northeast Chapter of the RBMA on April 16, 2010, in Tarrytown, New York). Massachusetts General Hospital’s decision-support experience will be covered in a future article.