Radiology Benefit Managers and Other Game Changers in Medical Imaging - This program is an educational activity supported by
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Radiology Benefit Managers and Other Game Changers in Medical Imaging This program is an educational activity supported by:
Radiology Benefit Managers and Other Game Changers in Medical Imaging Barbara Ossias Reimbursement Revenue Solutions, LLC bossias@reimbursementrevenuesolutions.com
Program Information Format: Text Only No Audio Effective Date: October 14, 2020 Expiration Date: October 31, 2021 Format: Self Instructional - Slides Educational Credits: One (1.0) ARRT Category A CE Credit. Estimated Completion Time: 1 hour Accreditation This course meets all criteria and has been approved by the AHRA, The Association for Medical Imaging Management for One (1.0) ARRT Category A CE Credit. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board or other credentialing organization. Method of Participation/Criteria for Success To receive CE credits for participating in this activity you must successfully complete the online post examination. Online examinations return an immediate grade report. Upon receiving a passing grade of 80% or higher click continue and complete the evaluation form. To view and print your Statement of Credit click the Print/View Certificate link displayed from within your User Record page.
Program Information 1. Course Objectives 2. Opening 3. Impact of Radiology Benefit Managers on Medical Imaging 4. How to Be Successful in a Challenging Environment 5. Other Game Changers in Medical Imaging
COURSE OBJECTIVES
Course Objectives
By participating in this presentation, you will
Gain an understanding of the impact of Radiology Benefit Managers (RBMs) on medical imaging
Have an overview of how RBMs work
Learn how to be successful in a challenging environment
Be aware of the other game changers in medical imaging
6OPENING
Opening
In 1993, an associate wrote “Diagnostic imaging is one of the
most capital-intensive specialties in medicine and as such, will
be targeted for health care reform over the next decade. As
costs associated with providing imaging services will continue
to increase, so will pressure to limit the use of imaging services
and reduce the reimbursement for work performed. And the
spread of managed care and other cost-saving programs will
lead to increased competition among providers of imaging
services”.
In 2020, we live with mechanisms put in place to control those costs
8Opening
These mechanisms limit access to care and at the end of the
day, there is varied opinion on their success and impact on
patient outcomes
A December 2019 article in “Radiology Business” states An
exhaustive comparison of diagnostic imaging use between
Medicare patients and the commercially insured may cast
doubts about the effectiveness of radiology benefit managers,
two radiology experts assert
In a comparison of utilization rates across several modalities in two insured
populations (traditional Medicare and commercial) from 2003 to 2016, researchers
learned that usage trends seemed to mostly mirror one another
9Opening
“The lack of substantial difference in imaging utilization
between these populations (including CT, PET and MRI)
otherwise expected to require preauthorization raises the
question of effectiveness of radiology benefits management to
control non-Medicare utilization,” wrote the authors, both MDs
from Weill Cornell Medical College
“This lack of effect on utilization trends further suggests that
cost savings realized by payers through radiology benefits
management are being achieved through alternate
mechanisms, such as steerage to lower-cost providers and cost
shifting” they added
10IMPACT OF RBMS ON MEDICAL IMAGING
The Impact of RBMs on Medical Imaging
For the past two decades, payers have segued from
commercial fee-for-service to marketing almost exclusively
managed plans
Exclusive Provided Organizations (EPOs)
Health Maintenance Organizations (HMOs) – the largest segment of
commercially insured patients
Preferred Provider Organizations (PPOs)
While the corporate line is “managed lives are healthier lives”
managed lives are less-costly lives
12The Impact of RBMs on Medical Imaging
In the move towards managed care as the norm, not the
exception, medical imaging has been scrutinized as a
cost center as opposed to a cost saver
Payers have decided if they control access to imaging,
they have a better control of cost
Often without thought to how early diagnosis can save
cost on treatment
13The Impact of RBMs on Medical Imaging
Commercial/managed care payers subject almost all
advanced imaging to prior authorization employing the use
of Radiology Benefit Managers (RBMs) such as eviCore
RBM partners act as “gatekeeper” for all advanced
imaging procedures – gatekeepers as ordering physicians
must go through them to be able to order a procedure
And they consider advanced imaging pretty much anything
above a simple x-ray or ultrasound
14The Impact of RBMs on Medical Imaging
RBMs develop clinical guidelines that are the basis for
approval and often these guidelines are highly restrictive
RBM oversight often has the effect of deterring use of imaging
by adding another layer of bureaucracy for ordering physicians
to deal with
Those making decisions at an RBM often have no
background in medical imaging and work off the approved
clinical criteria, with no leeway on interpretation
15The Impact of RBMs on Medical Imaging
The RBM clinical guidelines that are the basis for approval will
supersede any historical medical coverage policy from a
payer
Many payers no longer even both developing a coverage policy,
but rather simply go with the clinical criteria developed by their
RBM partner
16The Impact of RBMs on Medical Imaging
And it is not just commercial/managed care payers that
are requiring prior authorization
Medicaid fee-for-service and managed Medicaid plans are
requiring prior authorization
§ Fee-for-service programs usually perform prior authorizations internally
while managed plans will use the parent commercial payer’s RBM
partner
17The Impact of RBMs on Medical Imaging
Even Medicare Managed Care, AKA Medicare Advantage,
plans are requiring prior author for almost all advanced
imaging
And it is important to not these Medicare Advantage plans
do not cover exacting the same as CMS cover – most cover
per their commercial policies which are often more restrictive
than traditional Medicare
18The Impact of RBMs on Medical Imaging
RBMs are paid to say no and have been very successful at
doing so to the point the largest names in the business now
manage other areas of healthcare
As example, eviCore manages:
Cardiology services Post acute care
Gastroenterology Radiation oncology
Medical oncology Sleep disorders
Musculoskeletal procedures & Specialty Drugs
therapies
19The Impact of RBMs on Medical Imaging
And despite the mixed results on RBM management
discussed in the opening, this extreme oversight is here
to stay
20IMPACT OF RBMS ON MEDICAL IMAGING – HOW PROVIDERS CAN BE SUCCESSFUL IN A CHALLENGING ENVIRONMENT
Impact of RBMS on Medical Imaging – How Providers can be Successful
in a Challenging Environment
Know the medical coverage policies of the major payers
important to their practice
Know the clinical criteria of the RBMs these major payers
work with
Payers and RBMs for the most part publish medical coverage
policies and clinical criteria
And remember, do not count on these two components of
coverage matching!
22Impact of RBMS on Medical Imaging – How Providers can be Successful
in a Challenging Environment
Most payers do not even bother establishing policies,
or when they do, it will be only for a select number of
imaging procedures
An example of an established medical coverage policy is Anthem
Blue Cross Blue Shield for Breast MRI:
§ https://www.anthem.com/dam/medpolicies/abcbs/active/policies/
mp_pw_a053263.html
Most allow their RBM partner to develop clinical guidelines
23Impact of RBMS on Medical Imaging – How Providers can be Successful
in a Challenging Environment
Most RBMs have done away with human interaction –
clinical coverage guidelines and the PA process are all
online
As example, AIM Specialty Health is the RBM for Anthem
and they publish imaging criteria by body area, not
modality:
https://aimspecialtyhealth.com/wp-
content/uploads/2020/03/AIM_Guidelines_AbdomenPelvis_Imagin
g.pdf
24Impact of RBMS on Medical Imaging – How Providers can be Successful
in a Challenging Environment
Guidelines to successfully secure authorization
Perform a benefit investigation for each patient prior to
scheduling a scan
Find out of prior authorization is required
§ If required, what is the process – online, calling RBM partner, etc.
Never assume all coverage is the same with any payer
§ As example, while one Aetna plan may not require PA, but others
will – they sell over 450 plans, with varied coverage and
requirements
25Impact of RBMS on Medical Imaging – How Providers can be Successful
in a Challenging Environment
When coverage is in doubt, have a patient sign an
Advanced Beneficiary Notice (ABN) and enforce it where
you can
For situations where an office fails to secure required PA
they cannot enforce, but if they learn a service is non-
covered during the process, they can bill the patient
26Impact of RBMS on Medical Imaging – How Providers can be Successful
in a Challenging Environment
Know your payers - make sure before offering any
advanced imaging that those payers that are a large
part of your payer mix will allow the services in the practice
specialty
Learn if any payer RBM partners require the practice to be
credentialed by the RBM
HealthHelp, the RBM for Humana, requires all providers be
credentialed with them before they we approve any procedures –
they will not even initiate an approval until this has been done
27Impact of RBMS on Medical Imaging – How Providers can be Successful
in a Challenging Environment
Do not be afraid to appeal denied approvals – if it is a
covered indication, providers have the right to appeal!
Post-decision options for denials can vary, based on the
reason for the denial, the payer, the member’s plan, or even
the member's residing state
Depending on these factors and the amount of time that
has lapsed since the denial decision, providers may be
able to have a decision reevaluated via a Peer-to-Peer
Consultation, formal reconsideration, or appeal
28Impact of RBMS on Medical Imaging – How Providers can be Successful
in a Challenging Environment
During each of these stages, providers will be able to
provide additional clinical information verbally or in writing
In some cases, the RBM might also suggest an alternative
recommendation for a test their guidelines show as more
appropriate for the patient's condition
These post-decision options do not always offer the
potential for overturn of a denial decision
29Impact of RBMS on Medical Imaging – How Providers can be Successful
in a Challenging Environment
eviCore and other Radiology Benefit Managers have been so
successful at saying no and saving their payer partners cash
they have expanded their service offerings
eviCore now manages
§ Sleep studies
§ Clinical lab
§ Post-acute care
§ Specialty Drugs
§ Medical & Radiation oncology
§ Even gastroenterology
30OTHER GAME CHANGERS IN MEDICAL IMAGING
Other Game Changers in Medical Imaging
Payers are utilizing several tools to control access to imaging:
In-network vs. out-of-network
Place-of-service restrictions
UHC limits type of site that can offer certain services
Some BCBS plans will not cover mobile services for certain
modalities
Multiple modality restrictions
Horizon Blue Cross Blue Shield of New Jersey requires five or
more advanced imaging modalities are offered in a site
32Other Game Changers in Medical Imaging
Payers are employing other tools to control access to
imaging:
Requiring attestations that no purchased services are used
§ Humana’s RBM partner, Health Help, requires all provider to sign an
attestation that the perform all services and do not purchase any
services including reads
Limiting which specialties can offer imaging services
§ Despite sports clinics being logical providers of MRIs, some payer or
their RBMs will not allow imaging by that specialty
33Other Game Changers in Medical Imaging
Payers tools to control access to imaging:
Requiring accreditation
Reducing reimbursement
Clinical criteria guidelines
And every one’s favorite . . . . .
34Other Game Changers in Medical Imaging
. . . Reducing payment on advanced imaging procedures
Reimbursement to radiologists, according to a study
published in the Journal of the American Medical Association
in 2019, dropped by more than 19.5%, and reimbursement
to cardiologists dropped nearly 45% between 2006 and 2015
Medical imaging use in the US has dropped significantly
reduced access to the technology thanks to cuts in
reimbursement
35Other Game Changers in Medical Imaging
CMS is also starting to manage advanced imaging
The Protecting Access to Medicare Act (PAMA) of 2014,
Section 218(b), established a new program to increase the
rate of appropriate advanced diagnostic imaging services
provided to Medicare beneficiaries.
Examples of such advanced imaging services include:
computed tomography (CT)
positron emission tomography (PET)
nuclear medicine
magnetic resonance imaging (MRI)
36Other Game Changers in Medical Imaging
Per CMS, the program impacts all physicians and practitioners
that order advanced diagnostic imaging services and
physicians, practitioners and facilities that furnish advanced
diagnostic imaging services in:
Physician offices
Hospital outpatient departments (including the ER)
Ambulatory Surgical Center (ASC)
Independent Diagnostic Testing Facility (IDTF)
37Other Game Changers in Medical Imaging
This does not apply to Critical Access Hospitals (CAHs) and
PPS-exempt Cancer Centers
There will also be one-off exemptions:
If the ordering professional has a hardship exemption for any of the following
reasons:
§ insufficient internet access
§ EHR or CDSM vendor issues
§ extreme and uncontrollable circumstances
38Other Game Changers in Medical Imaging
CMS has educational information on the program available on
their website https://www.cms.gov/Medicare/Quality-
Initiatives-Patient-855 368 2736Assessment-
Instruments/Appropriate-Use-Criteria-Program
39Other Game Changers in Medical Imaging
Under this program, when a practitioner orders an advanced
diagnostic imaging service for a Medicare beneficiary, they
will be required to consult a qualified Clinical Decision Support
Mechanism (CDSM)
CDSMs are electronic portals through which appropriate use criteria
(AUC) is accessed
The CDSM provides a determination of whether the order
adheres to AUC, or if the AUC consulted was not applicable
(e.g., no AUC is available to address the patient’s clinical
condition)
40Other Game Changers in Medical Imaging
Many CDSM vendors are the main Radiology Benefit
Managers:
AIM Specialty Health Provider Portal
eviCore's Clinical Decision Support Mechanism
HealthHelp's Clinical Decision Support Mechanism
A complete lists of CDSM vendors that are CMS approved can
be found on the program website
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/Appropriate-Use-Criteria-
Program/CDSM
41Other Game Changers in Medical Imaging
This program was to be fully implemented on January 1st 2021,
but in the current COVID-19 environment has been pushed
back by one year to January 1st 2022
AUC consultations with qualified CDSMs are required to
occur along with reporting of consultation information
on the furnishing professional and furnishing facility claims
for the advanced diagnostic imaging service
Any claims that fail to append this information will not be paid
42Other Game Changers in Medical Imaging
2020 was to be the Education and Operations Testing Period,
which started January 1st, but now testing will run through 2021
During this testing period claims will not be denied for failing to include
proper AUC consultation information
Claims without full information will be denied for dates of
service after January 1st 2022
43RESOURCES
Resources
Radiology Benefit Manager Clinical Criteria
AIM Specialty Health:
§ https://aimspecialtyhealth.com/resources/clinical-guidelines/radiology/
eviCore:
§ https://www.evicore.com/solutions/health-plan/utilization-
management/radiology
National Imaging Associates:
§ https://www1.radmd.com/solutions.aspx
45Resources
Guerbet offers reimbursement support in partnership with
Reimbursement Revenue Solutions, LLC
Barbara Ossias
§ 603 324 7173
§ bossias@reimbursementrevenuesolutions.com
Toll free support Monday – Friday 9am to 5pm Eastern Time
855 368 2736
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