Study: Imaging insurance denials on the rise

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Denials to patients seeking critical imaging services by their insurance providers have doubled over the last four years, according to internal case management data released by the Patient Advocate Foundation (PAF). Some 90 percent of reversed denials for imaging services were covered by those health plans.

PAF examined the use of prior authorization programs for medical imaging services and found that, of the 4,360 patients who contacted PAF between 2007 and 2011 for help in gaining the test they needed, 81 percent of the insurance denials for imaging procedures were due to prior authorization programs.

On average, PAF’s professional case managers required 15.4 contacts per patient case to resolve the imaging issue.

The annual case load from 2007 totaled 953 and throughout the last year of the study PAF case managers assisted in 1,592 cases. Approximately one-third of PAF imaging cases involved uninsured patients, and another third of PAF imaging cases involved patients covered by commercial insurance. PAF imaging cases of uninsured patients nearly doubled during the four-year period.

The majority of PAF imaging cases had a primary diagnosis of cancer (80.4 percent), followed by 8 percent for screening for symptoms, and 5.1 percent for chronic/debilitating conditions.

The Medical Imaging and Technology Alliance and Access to Medical Imaging Coalition applauded the work and claimed the findings buttress the case for appropriateness criteria and decision support tools rather than prior authorization.