David C. Levin MD, Presenter: Consultant, HealthHelp Board of Directors, Outpatient Imaging Affiliates, LLC

Robert L. Bree MD, Abstract Co-Author: Consultant, HealthHelp

Cherrill Farnsworth, Abstract Co-Author: CEO, HealthHelp

Vijay Madan Rao MD, Abstract Co-Author: Nothing to Disclose

To describe the decision support process of an RBM and how it affects utilization of advanced imaging.

HealthHelp (HH) is a large RBM that performs prior authorization for several commercial payers. The database of a large payer was used to study the workings of the 3 tiers of decision support used by HH, and how they affected advanced imaging utilization.

During 2008, 404,612 requests for CT, MRI, and PET were recorded by the 1st tier service representatives, who used clinical rules to ascertain appropriateness. 299,961 (74%) met the rules and were approved. Ordering physicians decided to withdraw 4164 (1%). The remaining 100,487 (25%) could not be resolved and were then referred to 2nd tier nurses. They approved 82,598 (82%), changed or withdrew 8053 (8%), and referred 9836 (10%) to the 3rd tier, which consisted of a group of approximately 40 subspecialty radiologists (most of them in a single academic radiology department). These third-tier radiologists approved 6406 (65%) after phone consultation with the referring physician. In another 2881 cases (29%), the ordering physician agreed to withdraw the request. In 397 (4%), the procedure was changed to a more appropriate one. In 152 (2%), there was no consensus, but these were not denied. The entire process resulted in cancellation of 13,362 studies (3.3%) and the changing of 2133 (0.5%) to a more appropriate exam. But the overall effects on utilization were greater. Preliminary data from the payer’s largest markets showed that while the utilization rates of CT, MRI, and PET had been projected to increase 10%, 10%, and 45% respectively, in actuality the rates remained flat or dropped after the program was instituted in 2005.

An RBM working with clinical rules and a team of subspecialized radiologists was able to halt the upward trends in utilization rates of advanced imaging that are prevalent in the Medicare program and other commercial health plans. This was likely the result of a combination of the 3-tiered decision support system plus the “sentinel” or gatekeeper effect that is inherent in prior authorization programs.

Does not apply.

Levin, D, Bree, R, Farnsworth, C, Rao, V, A Call Center Offering Decision Support and Operated By a Radiology Benefits Management Company (RBM): Effects On Utilization.  Radiological Society of North America 2009 Scientific Assembly and Annual Meeting, November 29 - December 4, 2009 ,Chicago IL. http://archive.rsna.org/2009/8003072.html