UnitedHealthcare Accreditation Mandate: Why They Did It

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Last January, UnitedHealthcare, Edina, Minn, became the first insurer in America to require nationwide accreditation for all outpatient-imaging providers, effective March 2008. The mandate applies equally to all outpatient providers of MRI, CT, PET, nuclear medicine, nuclear cardiology, and echocardiography. Providers have a choice of being accredited by the American College of Radiology (ACR) or the Intersocietal Accreditation Commission (IAC). Why did United Healthcare—supported enthusiastically by the ACR—make the move? “We believe that our program addresses the quality and safety of imaging through the application of nationally recognized standards,” answered Laurie Paidosh, director, radiology programs, UnitedHealthcare. “It assures that the imaging equipment, physicians, and the technologists are in compliance with the appropriate performance standards. So bottom line, our goal is to advance the safety and quality of imaging services. Not Too Late It is not too late for imaging providers to apply for accreditation in time to meet UnitedHealthcare’s condition for reimbursement, through the American College of Radiology (ACR) or the Intersocietal Accreditation Commission (IAC) beginning March 2008. Imaging providers may seek accreditation from the ACR or the IAC. “It’s not too late for people to take action,” Laurie Paidosh, director, radiology programs, UnitedHealthcare, reassured. The insurer has mandated that all providers who bill under the CMS 1500 form be officially in the accreditation process by March 1, 2008. According to the latest information on the ACR web site, the college requires the submission of a completed application by January 15, 2008, in order to ensure that the application will be processed by the March 1 deadline. The broader story is that many of the factors driving the increased utilization of imaging drove UnitedHealthcare to action, according to Paidosh. The recognition of significant variation in the delivery of health care. “First and foremost, UH recognized that significant variations existed, and still exist today, in the quality, safety, and appropriate utilization of imaging services in health care delivery,” Paidosh explained. “So we know from evidence-based literature and professional society guidance that these variations affect…the quality, safety, as well as affordability of health care. We were really acting on behalf of our customers in terms of developing an initiative that could address those elements.” Growing consumer demand for imaging. “If you are a Baby Boomer, you are much more savvy about health care,” Paidosh noted. “The other piece is the direct-to-consumer advertising that occurs—get your heart study today, find out if you have clogged arteries—venturing out where the pharmaceuticals have been. You are seeing some of that now in imaging.” Greater access to imaging technology. “The next driver of increased imaging spend is greater access to imaging technology, meaning more non-radiologists have access to imaging technology,” Paidosh added. “It could be for patient convenience, it could be an economic factor, meaning there is an incentive, but you’ve got non-radiology specialists who are doing it, and it does lead to an increase in utilization.” Advances in imaging technology and technology applications. “New technology is growing significantly, and appropriately so,” Paidosh said. “New developments have made it very useful in terms of being able to diagnose more accurately, and with that you have new applications of existing technologies and new technologies that have come into play, PET being the most recent. The challenge for the referring physician is how to know what is the most appropriate study to use? Is it the CT, the MRI?” Widespread utilization of technology by providers. “Everyone is doing a little imaging, it is no longer necessarily concentrated in a few specialties,” Paidosh said. “Twenty years ago, most imaging was delivered either in a radiologist’s office or in a hospital setting. That has changed dramatically today in terms of having technology in physicians’ offices, mobile units, as well as outpatient hospital centers and freestanding radiology centers. So there has been a shift in the traditional environment.” In implementing its accreditation program, UnitedHealthcare is attempting to balance its challenges and opportunities, Paidosh said, challenges that include rapid and sustained growth, the widespread use and availability of expensive technology, and the significant variations that exist in quality, safety, and appropriate utilization. “We have an opportunity to improve quality and affordability,” she said. “When you package all of those things together, one solution for us is imaging accreditation.” Impact on Providers Accreditation will apply to radiologists, imaging centers, and other specialists operating in the outpatient arena with the following modalities: CT, MRI, PET, nuclear medicine, nuclear cardiology, and echocardiography. “The caveat here is when those services are performed using a CMS 1500 claim form or its electronic equivalent, they will be subject to accreditation with outpatient services,” Paidosh explained. When asked what kind of attrition the insurer expects, Paidosh emphasized that it is not the intention of UnitedHealthcare to narrow its network. “It’s important to know we are not terminating physicians from our network for lack of accreditation,” she said. “What it means is that if they provide services that are subject to accreditation, and they don’t have it, they will not be reimbursed for said services. That does not mean that we would terminate them from our contracted provider network.” However she does anticipate that some providers will choose not to pursue accreditation. “As we work with providers, our goal is to make sure that they all pass accreditation,” Paidosh said. “Candidly speaking, we know that there will be some that choose not to do it, maybe because of economic reasons, maybe they know the equipment is older and may not meet the quality standards.” Ultimately, Paidosh predicted that the accreditation program would have benefits beyond the UnitedHealthcare provider network. “If you are a UnitedHealthcare patient, a Medicare patient, or a Blue Cross Blue Shield patient, once that facility is accredited, everyone who goes there will benefit,” Paidosh said. “So all of the boats in the harbor will rise with this initiative.” Resources United Healthcare Physician Portal • www.unitedhealthcareonline.com ACR Accreditation Hotline: (800) 770-0145 ACR Accreditation Application Intersocietal Accreditation Commission