A four-year retroactive study by the Patient Advocacy Foundation (PAF) has determined that insurance should have covered 90 percent of some 4,000 Americans denied access to needed medical imaging services.
If these results are in any way microcosmic of Americans’ experiences nationwide, insurers and radiology benefit managers could be gumming up the healthcare system to an overwhelming degree, says Gail Rodriguez, president of the Medical Imaging & Technology Alliance (MITA).
“Between 2007 and 2011, 4,360 patients contacted PAF regarding insurance denials for imaging procedures,” reads a press release accompanying the results. “Of these, 81 percent of the insurance denials were due to prior authorization programs and 90 percent of prior authorization coverage denials were in fact covered by the patient’s health plan.”
The number of denials doubled throughout the course of the study, and PAF case workers were required to contact insurers more than 15 times per case, on average, to investigate why.
“We expected some dramatic results,” MITA president Gail Rodriguez tells Imagingbiz. “I don’t think we expected startling results."
Unwilling to attribute any motivation to the numbers, Rodriguez nonetheless deems the denials “arbitrary and capricious.”
“Clearly if 90% of these decisions were in fact covered, then there’s a lot of mistakes there,” she says.
Rodriguez said the results are particularly troubling when considering that the study captures only a small subset of patients who were self-selected; i.e., those who reached out to PAF for help.
“If the rest of the population doesn’t have recourse like these patients do, you can imagine the amount of money being saved [by insurers],” she says. “[These companies] must have extraordinary resources.”
Rodrigues adds that the results of the study make a strong case for keeping prior authorization out of Medicare.
“We need to be concerned about both [Medicare and privately insured patients] because the issue’s the same,” she says. “We don’t need RBMs and prior authorization policies getting between people and their doctors.”
Rodriguez noted that battling with insurers and their intermediaries is a significant drain on provider time and resources. (Another study released this week also showed that, across America, radiologists deem themselves lsee than competent in handling practice management and billing issues.)
“I’m hearing just anecdotally from some physicians the practice resources they’re having to dedicate to prior authorization is hours out of every day,” she says. “They work really hard to begin with and they didn’t go to school to argue with insurance companies.
“If we all use appropriateness criteria, which physicians are very receptive to, we hope these companies and Medicare would rely upon clinical judgment,” when deciding to cover or decline a study ordered by a physician,” Rodriguez says.
“That’s what we’re paying them for.”