Vermont tests elimination of payer pre-approvals for MRIs

The Green Mountain State is in the news for more than the entry of Independent Sen. Bernie Sanders into the 2016 race for president. A pilot healthcare-delivery project there experiments with removing a rule currently requiring patients to get pre-approval from their health plans for MRIs.

The Rutland Herald reports that, while the test initiative is underway, Vermont patients who are suffering pain in the lower back and covered by one of several plans can be sent directly for an MR scan of the lumbar spine by their referring doctor, no payer clearance required.

The payers participating in the pilot include Blue Cross Blue Shield and Vermont Medicaid. The participating providers are Porter Medical Center in Middlebury and Rutland Regional Medical Center.

The newspaper noted in an April 29 article that Vermont currently requires referrers to secure pre-approval for most MRIs, burdening already overscheduled doctors and stressing out patients in pain.  

“The fundamental relationship is between the physician and the patient,” Jean-Christophe Biebuyck, a diagnostic radiologist at Rutland Regional who is spearheading the project, told the Herald. “Then I have to get people without my training to approve my decision.”

The pilot is slated to run six months to a year. Its results will be sent to the Vermont legislature for consideration on points of care improvement, cost reduction and overall feasibility.

Biebuyck told the paper that the pilot’s success or failure will largely hinge on the willingness of referrers to back up their MRI orders with sufficient clinical documentation.

“We have to make sure we have enough data to show all parties that this may be able to save the system money,” he said, “and that prior authorization doesn’t have to occur.”

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