Utilization management program can reduce unnecessary imaging, costs
To contain imaging growth, combat misuse of technology and educate referring physicians about appropriate ordering of exams, David P. Friedman, MD, and colleagues have initiated a utilization management (UM) program—an alternate to pre-certification—directed by a radiology benefit management program, according to a study in the February issue of the Journal of the American College of Radiology.
Using evidence-based guidelines, the researchers launched a commercial UM program to provide “real-time decision support for physicians ordering expensive outpatient imaging studies.”
After consultation between UM personnel and a referring physician’s staff, studies not meeting appropriateness criteria are referred to an academic radiologist for review, the authors wrote. The radiologist either approved the study after reviewing the electronic chart or called the referring physician for further information. Studies were not denied by radiologists.
For health plans of one large payor, seven neuroradiologists reviewed 2,032 neuroradiologic studies during a one-year period, of which 80 percent were approved. The remaining 20 percent were initially withdrawn by consensus or by no callback.
Overall, the researchers found that 71 percent of the studies (208 MRI, 85 CT) initially not performed were not reordered (duration of follow-up, three to 15 months).
Hence, 14 percent of all studies reviewed were not performed about 6 percent of those ordered were reordered with a more appropriate exam. Friedman and colleagues estimated cost of scans not performed was about $150,000.
The authors concluded that “the participation of academic neuroradiologists in a UM program affected the performance of many expensive outpatient imaging studies. There was a durable reduction in unnecessary and inappropriate studies. These results demonstrate the utility of evidence-based appropriateness criteria in radiology UM programs and the power of the sentinel effect.”
Using evidence-based guidelines, the researchers launched a commercial UM program to provide “real-time decision support for physicians ordering expensive outpatient imaging studies.”
After consultation between UM personnel and a referring physician’s staff, studies not meeting appropriateness criteria are referred to an academic radiologist for review, the authors wrote. The radiologist either approved the study after reviewing the electronic chart or called the referring physician for further information. Studies were not denied by radiologists.
For health plans of one large payor, seven neuroradiologists reviewed 2,032 neuroradiologic studies during a one-year period, of which 80 percent were approved. The remaining 20 percent were initially withdrawn by consensus or by no callback.
Overall, the researchers found that 71 percent of the studies (208 MRI, 85 CT) initially not performed were not reordered (duration of follow-up, three to 15 months).
Hence, 14 percent of all studies reviewed were not performed about 6 percent of those ordered were reordered with a more appropriate exam. Friedman and colleagues estimated cost of scans not performed was about $150,000.
The authors concluded that “the participation of academic neuroradiologists in a UM program affected the performance of many expensive outpatient imaging studies. There was a durable reduction in unnecessary and inappropriate studies. These results demonstrate the utility of evidence-based appropriateness criteria in radiology UM programs and the power of the sentinel effect.”