Manage routine radiology: Opportunities to control costs and improve care
The pressure on health plans is increasing, and they bear costs while providing high-quality care. When they look for opportunities to improve efficiency, they will wisely consider the management of conventional radiology claims.
Although advanced imaging modes such as CT, MRI, and PET are often subject to prior authorization (PA), conventional radiology, including X-ray, ultrasound, and non-cardiac nuclear medicine, are often not. Because it is more common and has lower cost per unit, routine testing has little or no basis for whether the plan is consistent with best practice guidelines or follows the plan. This kind of oversight presents both a challenge and an opportunity to plan.
Wasteful use
The United States spends about $100 billion on medical imaging every year, and studies show that 30% of this expenditure may be unnecessary. This is an unnecessary financial loss to an overburdened healthcare system. In addition, unnecessary imaging allows patients to avoid avoidable radiation risks and unnecessary medical interventions.
In 2022, claims for business health plans with 700,000 members were reviewed, revealing claims for medical imaging for each member (PMPM) per month. About $137 (or 35%) of which are used for routine radiology. Although these services cost less per unit than advanced imaging, their large amounts make them a huge expense. Analysis shows that approximately 8% of conventional radiological claims are inconsistent with established standards of care. Some frequent examples of waste habits include:
1. Preoperative chest X-rays of healthy patients – Guidelines dissuade routine chest x-rays before surgery to understand asymptomatic, healthy patients. Despite such standards of care, these procedures are often ordered in reverse. In the dataset, only over 8% of the claims for chest X-rays are inconsistent with these guidelines, which provides a clear opportunity to reduce unnecessary radiation and costs.
2. Repeated or redundant exams – When more complete exams cover limited coverage, clinicians may order complete and limited examinations in the same area (e.g., abdominal ultrasound or limb imaging). In the sample data, about 7% of the abdominal ultrasound pictures were repetitive or unnecessary.
3. Overuse of the Bone Age – This test is used to assess bone maturity and should be retained for specific pediatric indications and should be performed no more than once a year. However, in 14% of the review cases, it was overused or not explicitly directed.
Solution: Automated, policy-based claims management
The management of routine radiology does not require prior authorization administrative burden. Instead, health plans can be managed automatically after implementing services in accordance with clinical guidelines. The following are:
- Automatic rule application – Assess claims in real time to align with a range of conventional radiological policies that align with national standards and program-specific preferences.
- No delayed care – Unlike PA, this model does not delay patient care and does not put members in the responsibility of paying for unwanted exams.
- Improved provider behavior – Refusal to be coded as provider responsibility, and compliance with guidelines is encouraged through feedback rather than interruption.
Benefits of routine radiological management
Routine radiological management can improve its outcomes by helping ensure that the right patient gets the right diagnosis at the right time. Patients will also benefit from reducing exposure to radiation caused by unnecessary imaging and any risks resulting from downstream care. Fewer tests also mean fewer false positive results can lead to unnecessary care and higher costs. Members also do not have to pay out of pocket for inappropriate care.
The automated management model also provides claims decisions, reports, and education to providers who are more likely to adhere to policy guidelines when ordering routine imaging.
The program will benefit from promoting high-quality, cost-effective care, with an estimated savings of $1 pmpm. Furthermore, the combined effects of these benefits will support the transition from healthcare to value-based care.
Why routine radiology management is a good idea
With plans controlling spending and out-of-pocket expenses for members, while improving care, it makes sense for them to re-examine areas that were previously unmanaged.
Given the number of tests and the high incidence of non-compliance with planning policies, routine radiology is one of them. An automated evidence-based approach is a simple and necessary step towards controlling costs and improving care.
Photo: Egor Kulinich, Getty Images
Jim Koger, Vice President, Avalon Healthcare Solutions, is an experienced healthcare product manager dedicated to enhancing access to affordable care by developing innovative, professional welfare management solutions. He stressed the importance of advancing routine diagnosis in the fields of laboratory testing and radiology.
Mark Hiatt, MD, MBA, MBA, MS, is a Stanford-trained radiologist with career leadership roles in the radiology department, health systems, radiation welfare management companies, health programs, health programs, and radiology accredited institutions. He developed programs to ensure the appropriateness, quality and cost-effectiveness of medical imaging and provides companies with advice on optimizing clinical validation and market access strategies. He advocates evidence-based imaging management to support quality and sustainability.
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