Radiologist Marc Liebeskind, MD, doesn’t need to strain his memory to recall a time when he saw a health insurer’s authorization process come between sound clinical judgment and a patient’s clearly indicated care.
Not so long ago, a patient with intermittent flank pain had to wait—and wait—for her kidney CT scan to be approved because she’d recently had an ultrasound of the same organ. The delay made sense to nobody but the insurer, says Liebeskind, owner of Park Avenue Radiologists (PAR), a multimodality, state-of-the-art freestanding imaging center on the Upper East Side of Manhattan.
Liebeskind wasn’t surprised when the CT produced the evidence for a definitive diagnosis where the ultrasound hadn’t. The episode “ended up turning into an opera that didn’t need to be sung,” he says. “And we see situations like that every single day.”
It was the predictable unpredictability of such situations in daily practice that spurred Liebeskind, along with PAR’s business manager Zorina Arjune, to select and install iConnect® Network Services (iCNS) from Merge Healthcare in early October.
“We sometimes have no idea why one case gets paid and another does not,” Liebeskind says when asked about the timing of the strategic software deployment. “We were seeing too many denials.”
PAR has installed the full iCNS platform, although it’s only using iCNS Authorize to start. Decision support and utilization management are integral attributes of the platform, which consists of three modules: iCNS Orders which simplifies and streamlines patient referrals; iCNS Results which electronically distributes exam results; and iCNS Authorize which automates pre-authorization of insurance coverage.
iCNS Authorize gives PAR the ability to establish medical necessity on the front end and, if necessary, counter a denial on the back end. It does this with imaging-specific expertise powered by the support of the iCNS team in collaboration with industry-leading Radiology Business Management (RBM) companies, eviCore and AIM Specialty Health. Their collective focus is helping hospitals and imaging centers comply with payers’ policies and physicians’ clinical decisions to minimize claims denials.
“Sometimes a patient who really needs a procedure calls in and has trouble explaining or understanding” the particulars of his or her case, Arjune says. “That can create a denial of authorization for ‘not medically necessary,’ or the case gets denied for payment even after authorization because of issues related to communication.”
“iCNS Authorize allows us to take patient data directly from the chart, feed it into an automated decision-support engine and then have the radiology benefits managers use that as their criteria,” Liebeskind says.
Decision support for the business side
Both Liebeskind and Arjune like the potential iCNS has shown to foster cooperation among (and between) the practice and insurers, referrers, radiology benefits managers (RBMs) and, of course, patients.
For example, the system allows PAR to handle all authorization work so referrers don’t even have to think about the complex and time-consuming process. This has them looking forward to long-term growth in referral volumes.
Since referring physicians are the frontline customers of any radiology practice, Liebeskind expects the combination of handling authorizations while serving as true clinical consultants—the doctors’ doctors—will set PAR apart from other radiology practices in the area.
“Our job is to consult with our referring physicians in the private marketplace,” he says. “We are not gatekeepers. We are not here to determine whether or not the MRI is indicated. That’s a decision to be made by the treating physician, and we don’t want to be in a confrontational relationship with our referring physicians.”
The need to sustain strong relationships with referrers, especially in a climate of financially driven provider consolidation, was top of mind for Liebeskind and Arjune when they looked at iCNS.
The platform facilitates “a huge cooperative effort,” says Liebeskind. “I love the idea that it is automated decision support and that we can improve our datasets over time. This makes us very hopeful. We’re looking forward to seeing not just logical authorizations and [prompt] payments but also more efficient patient management.”
Automated authorization station
A maximally efficient practice has more time to maintain its focus on helping patients. And it goes without saying that a desire to help patients is a prime driver behind most clinicians’ choice of career.
Illogical, inconsistent or otherwise wrong-headed coverage denials “create tension and unnecessary disruption in medical delivery, including when patients get billed inappropriately. Healthcare delivery really should not be like that,” Liebeskind says. “I expect automated decision support to allow us to mitigate that kind of bad decision-making.”
“We were very eager to be out in front of the automation evolution in medical business management,” he adds, “as opposed to continuing to feel like payment decisions were either arbitrary or dependent on whom you get on the phone or where you are in a billing cycle.”
He’s right to feel like an early adopter of a game-changing solution. iCNS Authorize not only electronically handles and processes imaging orders but also obtains the prior authorization from the appropriate payer. In addition, the payment model is flexible, so you can choose how often you want to use the services, which provides control over how much the practice is actually spending.
Prior to going live with iCNS Authorize, PAR was handling authorizations for 76 referring physicians. In just a few weeks, PAR has added 61 more referring physicians as a direct results of offering this service. Armed with new found confidence, PAR plans to expand its reach to the outer borough referring physicians.
PAR has also experienced significant cost savings since implementation. The solution’s automation has allowed the practice to shift some of its budget from payroll to equipment. As a result, PAR has a new MRI scanner and is optimistic about the practice improvements on the horizon.
Buoyed by the early indicators of successes, both Arjune and Liebeskind express enthusiasm over iCNS’s potential to one day leverage AI logic for automating decision support ever more intelligently.
“There has been so much that has been frustrating and not logical about our healthcare environment over the past few years,” he adds. “This is a window into a future where, if all goes right, things should make sense. We are incredibly optimistic about that.”