Blue Cross imaging rules curtailing use

PROVIDENCE – A policy instituted in January by Blue Cross & Blue Shield of Rhode Island that requires “pre-certification” for MRIs, CT scans, PET scans and two other high-end radiology procedures has cut down substantially on utilization, a key official for the insurer said last week.
Dr. Gus Manocchia, chief medical officer for Blue Cross, said about 8.5 to 9 percent of imaging studies requested under the new policy – which applies to outpatient procedures, but not to hospital inpatients or to emergency rooms – are being denied each month.
In addition, Manocchia said, there has been a bit of a “sentinel effect,” with requests for MRIs and other high-end imaging down slightly overall, though by how much, he could not say yet.
For Blue Cross, that reduction is a welcome change from the steady increase in high-end imaging – and the accompanying costs – the insurer had been seeing for years.
Utilization had been rising by about 8 percent per year, and in 2006, Blue Cross spent about $78 million on outpatient CT scans and MRIs alone, for almost 150,000 procedures, Manocchia said. (For perspective, that’s about one MRI or CT scan for every five Blue Cross members.)
Across the nation and in other countries, insurers have been limiting access to high-end imaging for years to try to stem the growth; as of late last year, 28 of the 39 plans that are members of the Blue Cross Blue Shield Association, including Blue Cross Blue Shield of Massachusetts, had “radiology management” programs of some kind in place.
But providers in Rhode Island had resisted previous attempts by Blue Cross to do the same here, and the Rhode Island Medical Society had urged the insurer to instead try educational efforts in collaboration with doctors, said Newell Warde, executive director of the society.
“We said to them, ‘Please don’t do this, because it’s hard enough to schedule these tests now for patients, and if you put this extra hurdle in the way and you’ve got people sitting on the phone lines and delaying the tests people need. It’s really going to create a burden, especially for primary care practices,’ ” Warde said in an interview.
But Manocchia said other insurers’ experience suggested that needless high-end imaging is a common problem nationwide. In a Blue Cross newsletter, Dr. Gregg Allen, chief medical officer of the contractor hired by the insurer to handle the pre-certifications, MedSolutions Inc., cited estimates that more than $16 billion is spent each year on unnecessary high-tech imaging. He also noted that while in 2006, such tests cost about $120 billion nationwide, this year, it’s expected to be $161 billion.
MedSolutions uses national guidelines to determine when a procedure is considered medically necessary. Doctors who want to order, say, an MRI for their patient have to call or fax the company or else go online to request the procedure; if the request is denied, there’s an appeal process as set out by the R.I. Department of Health, Manocchia said.
Asked how many appeals there have been, Manocchia said that through May (the program began Jan. 1), there had been “about 400,” and a fair number of those were successful. That’s a low number, however, given the “tens of thousands” of imaging requests, he noted.
But providers do report noticing a decline in imaging, and for those who do imaging themselves, an accompanying decline in revenue.
Jeanne LaChance, chief financial officer of The Westerly Hospital, said outpatient high-end imaging is down about 10 percent, though it has started to rebound, “because they’re just performing other tests first before they get an MRI.”
Edward J. Quinlan, president of the Hospital Association of Rhode Island, said each hospital has been affected to a different extent, but they all have seen some reduction in procedures.
However, both Quinlan and Warde, of the Medical Society, said that while the initial implementation of the program was burdensome, Blue Cross has made changes that made things easier – most notably, agreeing to let radiologists, rather than the doctors who order the imaging, go through the pre-certification process.
For example, Warde said, oncologists were really worried about delaying studies that could detect cancer, and Blue Cross allowed them to just give “prior notification” as opposed to having to get pre-certified or else have the claim denied. Similarly, cardiologists are talking with Blue Cross about making some adjustments, Warde said.