10 Things an RBM(Radiology Benefit Manager) Won't Tell You

1. What their criteria is. Guidelines are posted on most RBM websites but criteria for decision making is not that transparent.

2. If the health plan will actually pay for the test or not. You can get prior authorization but the health plan has the final say as to whether or not they will pay for it.

3. The best way for you to submit clinical(telephonic, web or fax). They won't tell you what is the fastest way to get a response.

4. How to provide clinical. They will ask you questions about the patient but won't teach you how to do it.

5. The most common mistakes medical office staff make. There are a lot of common mistakes that staff are not allowed to share with you.

6. How to make sure your fax gets processed properly. There are key facts to know about properly faxing your prior authorization request.

7. They get frustrated too when callers are not prepared or faxed/internet requests are incomplete.

8. The medical provider can speak with a medical director at any time during the prior authorization process.

9. How to make your charting prior authorization friendly. It is easier for clinical reviewers to approve studies when medical office notes are complete.

10. The medical provider can write on the Rx, “add IV contrast if required”. For most health plans, the test must first be approved without IV contrast. It can be upgraded later if it can be justified.

Controlling Medical Costs

In January 2010, Dr. Howard Brody, MD, PHD wrote an article, Medicine's Ethical Responsibility for Health Care Reform — The Top Five List. He prescribes taking the top 5 tests and treatments that are the most expensive and commonly ordered for each specialty and creating universal guidelines(developed by clinical epidemiology, biostatistics, health policy, and evidence-based appraisal) . Once these guidelines were agreed upon by each specialty, there would be an implementation of that particular specialty to discourage the use of these tests, etc. by their members to help lower health care costs.

This solicited many responses from physicians across the country. Some physicians said, "yeah, this a great idea" and some commented, "you have got to be crazy". Someone described it as "Utopia".

Correct me if I am wrong, but is that not what RBMs claim they are doing? RBMs state their guidelines are based on the American College of Radiology, physician specialties, clinical practice and research. Of course, there is debate among some (ACR, for one) that they are actually using evidence-based guidelines but they are not as transparent as some would wish them to be.

I agree with Dr. Brody. I believe specialty societies should take the lead. They should be the ones creating evidence-based guidelines, implementing a system to support those guidelines and supporting their members when they use them.

I also believe in tort reform. Physicians should not be punished for using those guidelines and they need someone to cover their backs.

Unfortunately, as it stands now, physicians are at the scrutiny of health insurance companies and RBMs for most tests and procedures they order. If specialty societies would take a more proactive stance when it comes to evidence-based guidelines for all tests and procedures, it would show they actually care about being a part of health care reform. They are the ones best suited for the job not the government, health insurance companies or RBMs.

The Future of Health Care

Ten years from now where will health care be? Will all Americans have health insurance? Will health care be delivered in the best way possible? Will costs be contained? No one knows for sure. But we can be the ones who shape the future of health care delivery. Right now we can be the ones who can make sure that our children and grandchildren will have fair and competitive health insurance rates, high-quality health care and the peace of mind that comes with it. I say we stop blaming and start finding solutions.

Health Care Reform is Law. Now What?

There is a big debate going on right now about the passing of health care reform. There is a lot of ranting and rhetoric floating around. But just like any other historical passage of a controversial bill, ie, Social Security, Medicare and Medicaid, things will settle down. The masses will settle down. In the meantime, there are patients to take care of. It is my hope that medical providers will take the time to really study how the law will affect them and their patients. Just watching CNN or Fox is not going to give them the real facts. That is a fact! I believe that if you take the politics and pessimism out of the picture and begin to see the law for what it is, a way for many patients to finally get care that they have not had for years. We will be a healthier society, a more productive society. Quoting John Lennon, "Some may say I'm a dreamer, but I'm not the only one."

Doctors have to find ways for their medical offices to be more cost efficient. They have to be better business persons. It's time to stop complaining and do what needs to be done to accomplish this. Sure there are going to be challenges and more red tape in some areas. But if you face it head on and be prepared for it, you can overcome it. You can see your practice grow and more patients can receive care. Isn't that what you got into medicine for? I hope so.

My website is currently down for repairs. Hope to be back up next week!

Health Care Reform and Effects on Prior Authorization

There will be some type of healthcare reform. At this time, no one is quite sure exactly how it will pan out. But there is one thing that will not change. That is prior authorization for advanced imaging. No matter what, medical providers will still have to justify why the test is needed.

Health care is cost driven. In order to control the costs of advanced imaging, the need for the test must be documented. The prior authorization process itself may change. The American College of Radiology is pushing to cut out the middle man (radiology benefit managers). They are recommending Electronic Decision Support(EDS), an online software program that determines appropriateness. This program will allow medical providers to input the clinical information which will automatically rate the appropriateness of the test being requested. It may also suggest an alternative test. If the medical provider does not accept the recommended test, they will be required to have a peer-to-peer discussion or talk with an onsite radiologist.

What will not change in this process is the fact that medical staff must still input the correct information. Even one small error can send a case for further medical review or if using the EDS system, spit out an inappropriate rating, causing delay.That is where my training program can help. I can teach medical office staff how to provide accurate clinical, avoid the most common mistakes and make the most of their time doing prior authorizations. Contact me for a free consultation on how I can help you today!

Is your patient getting the test they need at the right time?

The doctor orders an MRI, CT, PET scan or nuclear medicine scan for their patient. The paperwork is given to medical office staff to get prior authorization, aka precertification from the health insurance company. You call in and give the medical insurance information, study requested, CPT code, diagnosis, demographics of the patient, site and medical office. Then you are transferred to a clinical reviewer, usually a nurse. Questions are asked about the patient's medical history, signs and symptoms and physical exam findings just to name a few. This is where most medical staff have problems. The answers to these questions will determine if the test is needed. If it is not immediately approved, the case is sent for review to a medical director, who is a physician for the health insurance company. This can take up to two business days if it is not medically urgent. If the medical director asks for additional information, add about another two days for the medical office to respond. Add about another two days for the medical director to make a final determination. In the meantime, you are waiting for an answer. The patient is waiting to have their test done. This is frustrating for everyone involved. It is my experience that 1 out of 3 medical office staff are unable to provide complete clinical. This results in an automatic medical review.
This is where I can help you. No matter what experience you have had with prior authorization, you can benefit from my educational program. I can teach you how to be a "pro" at providing clinical, understanding the study being requested and give many, many tips on how to avoid the red tape and help you to be more efficient in this process. Contact me today to talk about how I can help you right now.