Insurers Hire Radiology Police to Vet Scanning [View All]

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NOVEMBER 6, 2008

Insurers Hire Radiology Police to Vet Scanning
Firms Make Doctors Justify Costly CTs, MRIs and PETs; Patients 'Stuck in the Middle'
By ANNA WILDE MATHEWS
WSJ

Health insurers are increasingly relying on outside firms to help rein in the skyrocketing costs of imaging scans like MRIs. But when these middlemen clash with doctors about what tests are needed, consumers can get caught in the crossfire. Big insurers including Aetna Inc., WellPoint Inc. and Cigna Corp. have hired so-called radiology benefits managers, or RBMs. Health plans say they want to ensure that doctors use high-tech scans only when it is clear that patients will benefit. The RBMs say their guidelines are based on scientific evidence and medical groups' recommendations. Often, the firms require doctors to get permission to do a scan before the insurer will agree to pay for it. "There's a lot of new technology, and it's emerging faster than physicians' knowledge" of how to use it, says John Jesser, a vice president for health-care management at WellPoint. An RBM can offer the most up-to-date, best-researched information on when to perform an imaging scan, he says.


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Edward Agura, an oncologist at Baylor University Medical Center, wanted to monitor a patient, Dallas resident S. Blaine Porter, with PET scans every three months for two years after Mr. Porter, 47, was treated for aggressive lymphoma in 2006. Dr. Agura and Mr. Porter say RBM American Imaging Management and Mr. Porter's insurer, Blue Cross and Blue Shield of Texas, a unit of Health Care Service Corp., required pre-approval for each scan, which delayed the tests. As a result, they say, Mr. Porter waited around four months or more between PETs. In July 2007, Mr. Porter had a seizure that turned out to be caused by a new tumor, this one between the two lobes of his brain. Dr. Agura says he believes that the new brain tumor might have been detected earlier if the scans had taken place promptly every three months. "Every time we scanned him, we had to go through a lengthy approval process," he says. "Delays in approval lead to cancers coming back and not being detected."

In a statement, Blue Cross and Blue Shield of Texas says it didn't deny requests for Mr. Porter's PET scans, and it found "no evidence that processing delays ... compromised the member's health or medical condition." The insurer said that in two cases, it responded to requests within four to seven days, but then there was a wait before Mr. Porter actually got the scan. American Imaging says it can't comment on specific cases, but it generally processes reviews promptly.

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There is evidence that a significant number of scans ordered by doctors aren't needed. A recent Government Accountability Office report noted that Medicare spending on scans varied sharply by geographic region, suggesting that the procedures weren't all "necessary or appropriate." Other research has shown that a substantial portion of imaging tests are ordered by doctors who have a financial stake in the imaging equipment being used, a potential conflict of interest. Physicians may also order imaging tests that aren't always necessary to protect themselves from liability. Excessive use of scans is a particular worry with CT, because it can expose people to high doses of radiation. The three big RBMs say they generally give ready approval to 70% or more of doctors' requests for scans, after the physician's office provides some basic information. Still more scans get authorized after doctors have in-depth conversations with RBM representatives, the companies say.

Here are some pointers to help consumers navigate the radiology-benefit model.

If your doctor does recommend a scan, you may want to check whether you fit professional guidelines from medical groups such as the American College of Radiology and the American Cancer Society. You also can avoid duplicate scans by telling your doctor when you've already had a test, and bring copies of earlier exams to your appointments. If your scan is approved by a contractor, you might still want to double-check with your insurer. Doctors say they periodically see snafus like the one that happened to Edward Latham, an architectural consultant from La Grange, Ill.

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Patients should check whether an imaging facility is accredited by a group like the American College of Radiology or the Intersociety Accreditation Commission, either by asking or checking the ACR's Web site. Depending on your out-of-pocket payment for scans, you may also want to ask about pricing, which can vary widely. Some insurers, including Cigna and WellPoint, post pricing data on their Web sites for various facilities. If your health plan or RBM denies coverage of your scan, you or your doctor can appeal. Typically, doctors can discuss the case with a staff physician at the RBM. And your insurer likely has a formal appeals process that you can use. If your appeal is rejected, you can often further appeal through a state process.

http://online.wsj.com/article/SB122591900516802409.html (subscription)