The American College of Radiology (ACR) and the Radiology Business Management Association (RBMA) have developed best practice guidelines for third-party payors, managed care organizations (MCOs), radiology benefit managers (RBMs), and imaging providers for use when implementing or evaluating a radiology benefits management program (RBMP). The guidelines were developed as a result of member feedback to the ACR and RBMA due to the proliferation of RBMPs throughout the commercial health insurance industry as one of its strategies to reduce the growth in imaging costs.
The college said it does not endorse RBMs or their approach to the marketplace, but "recognizes their current role in imaging utilization management and seeks to improve the strategies used by these programs regarding burdens created for providers and their patients."
RBMs are usually contracted to determine the appropriateness of imaging tests that are ordered, however some payors and MCOs also institute their own pre-certification or prior-authorization programs internally.
The guidelines include the following:
- The pre-certification process should cover a family of codes and not a specific CPT code: Having a CPT-specific prior-authorization program provides the imaging provider with the clear incentive to perform only the exam as ordered and authorized. Add-on codes which supplement an approved exam, e.g. ejection fraction evaluation for nuclear cardiology, CPT code 78480, should not require additional approval or certification--it should be included in the family of codes pre-authorized.
- Individuals with a clinical background with detailed and extensive training on imaging modalities should be the RBM decision makers: Making such decisions for prior authorization and pre-certification requires a medical background and a demonstrated ability to use the information in the patient care environment.
- When the radiologist is not in control of the pre-certification process, e.g. hospital-based imaging services, the professional component of the procedure should be paid by the insurance company even if the claim is denied for pre-certification reasons: The radiologist only relies on the presenting clinical information in performing the ordered study; the professional claim should be paid if denied for administrative reasons.
The ACR said it is confident that, if implemented, the guidelines will result in "a uniform process that would ease the administrative burden on payors/MCOs, ordering physicians, and imaging providers, and could function as benchmarks for RBM performance."
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