Removing denial provisions from utilization management systems does not increase imaging utilization and, in fact, a collaborative system actually reduces the use of advanced diagnostic imaging, according to a study published online April 29 in the Journal of the American College of Radiology.
The results contrast with the view that denial provisions—which refuse payment for studies not considered appropriate by the preauthorization system—reduce use, and that allowing physicians to order exams not endorsed by the system would lead to utilization growth, according to Jeffrey D. Robinson, MD, of University of Washington, Seattle, and colleagues.
“A collaborative utilization management system that does not deny payment, interfere with the doctor-patient relationship, or force test substitution could reduce the friction associated with utilization management without necessarily increasing expenditures on imaging,” wrote the authors.
Results of the study were based on a retrospective review of records from HealthHelp, a national imaging utilization management company that works with health insurance plans. The company’s process is similar to other radiology benefits management systems in that it sets rules for which exams are considered appropriate based on indications, and suggests alternatives if a requested study doesn’t meet guidelines. However, unlike other systems there is no denial provision, and a provider may go ahead with a request that isn’t indicated, explained Robinson and colleagues.
The no-denial preauthorization system was in use in all but four geographic markets for CT, MRI, PET and nuclear cardiac imaging studies, which represented the experiment group. The denial provision in these remaining markets was eliminated in 2010, and the authors reviewed 247,117 imaging requests from the 21 months before and 16 months after the switch to a more collaborative preauthorization model.
Compared with matched control markets, in which a collaborative model was in use for the entire study period, the utilization growth rate in the experiment group decreased slightly by 0.10 requests per 1,000 covered lives, reported the authors. Approval rates were unchanged.
Robinson and colleagues suggested that the educational process provided by the authorization consultations countered the natural tendency of people to take what they can get, even if at the end of the process an imaging request is granted regardless of its appropriateness based on guidelines.
The authors noted that any external attempt to change behavior through utilization management could be regarded as adversarial to a degree. “The physician-to-physician component of the preauthorization process does not have to be adversarial, however. Relying on the collaborative nature of the radiologic consultation rather than potential denial of imaging requests does not increase utilization.”