Decision support application helps head off denials

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Radiology benefit management (RBM) firms have sprung into existence the past few years to address the over utilization of high-end (typically defined as CT or MR) imaging procedures in the United States. These companies act as a mediator to insure that an ordered diagnostic imaging procedure meets American College of Radiology (ACR) Appropriateness Guidelines and/or criteria set by the payor to whom the exam will be billed.

For practices dealing with an ever-increasing volume of diagnostic imaging procedures by their referring clinicians, RBMs are often viewed as a roadblock to a smooth operation. Denials from an RBM for an exam result in contacting the ordering physician to explain the reason that the order has been turned down, which is rarely received in a warm and gracious manner by harried clinicians.

A group at Massachusetts General Hospital in Boston has developed a decision support program (DSP) that provides appropriateness scores and utility zones for CT and MRI exams. According to Praya Dang, MBBS, who presented an overview of the application at the 2007 Radiological Society of North America annual scientific assembly, this information can be helpful in identifying patterns of radiology referral practice. In turn, a department or imaging center can use this information to determine which of its referrers would most benefit from appropriateness criteria mentoring.

“Our decision support program allows for the evaluation of appropriateness trends for high-cost imaging tests,” said Dang. “Based on the likely yield of the requested imaging exam for given clinical indications and patient demographics, the DSP provides appropriateness scores and utility zones.”

Researchers at the facility determined appropriateness patterns in CT and MRI exams for patient demographics, clinical indications, and body regions being imaged. The criteria were set based on ACR Appropriateness Guidelines and discussions with physicians, according to Dang.

“The DSP allows monitoring of appropriateness patterns based on age, gender, modality, clinical indications, and body regions being examined,” she said.

The group recorded appropriateness scores as low, intermediate, or high for 63,088 CT exams and 37,316 MRI studies between 2005 and 2007. They used a RadCube (Commissure) interface to extract this information for different age groups, gender, clinical indications and body regions (abdomen, chest, cardiac, musculoskeletal, head and neck, spine, vascular, nuclear medicine, and others) being imaged. Dang said the data were analyzed using logistic regression.

For CT, a maximum prevalence of low appropriateness scores was recorded for the age group of 11-20 years (4.7 percent), males (1.2 percent), and non-neoplastic indications (2 percent), Dang reported. For MR, the maximum prevalence of low scores was in the age group of 0-10 years (4.9 percent), males (4.2 percent) and non-neoplastic indications (3 percent).

She said that appropriateness scores were significantly different for body regions imaged (p <0.0001). Low appropriateness scores were most prevalent for spine exams (11 percent) and were least common for chest exams (0.1 percent), Dang noted.

The data have helped the facility identify which exams for which body regions for which patients are most likely to not meet appropriateness criteria. This, in turn, has allowed it to devise strategies to effectively mitigate these situations.

“Our decision support program allows evaluation of appropriateness trends for high-cost imaging tests, which can help us to identify outliers and then target specific correction measures,” she said.