As a former clinical reviewer for one of the largest Radiology Benefit Managers in the country, I often witnessed inappropriate requests for advanced imaging. After collecting patient clinical to include the type of test ordered, if it didn't match up to our criteria, it was sent for further medical review by an RBM physician. At which time, it was either approved, denied or a request for additional information was sent to the ordering medical provider. There are other reasons advanced imaging is ordered inappropriately, this post will focus mainly on education.
For example, there was one obstetrician, who only ordered non-urgent CT scans for his pregnant patients. Even after I recommended MRI, he refused. Of course, these were always sent for further medical review to the RBM physician. We received many requests for spine MRIs, especially lumbar spine MRIs for acute low back pain without injury. Of course, most of these were sent for further medical review, having lacked proper conservative treatment.
So whose responsibility is it to make sure the patient is getting the right test at the right time? Originally, it must rest on the medical provider. He/she is the one who has initial contact with the patient and should make an educated decision about what test is the right test and when. If they are not sure, they should speak with a specialist or radiologist to determine the proper test. There is nothing wrong with that. It is impossible for medical providers to know what test is the correct test for all diagnoses. As a clinical reviewer, a large part of my job was educating medical providers and staff in regards to the appropriate test.
Secondly, the next person responsible for getting the right test is the radiologist. As an example, when an order is received for a brain MRI without contrast and it includes the pituitary gland, it is the radiologist's responsibility to make sure the test is done with contrast. A brain MRI without contrast will not visualize the pituitary gland. Sure, that may mean a phone call to the RBM, health insurance company or the ordering physician, but it means the patient will get the right test. Many times, I saw brain MRIs being performed without contrast (as ordered by the physician) to visualize the pituitary gland. This is a waste of time and money. Because that means the patient has to return to redo the MRI with contrast.
If the first two lines of responsibility are neglected and the ordered study is presented to the RBM or the health insurance company for prior authorization (precertification), it then becomes their responsibility to educate based on evidence-based guidelines and safety. Sure, there will always be some physicians who disagree with the RBM or health insurance company's guidelines. That happens.
I will get to my point here as I could go on for days about the over-utilization and inappropriate requests for imaging I witnessed. And not that I am on the RBM bandwagon, because I think there are better ways to handle requests for advanced imaging.
There are good evidence-based guidelines out there. Most RBMs and health insurance companies use ACR (American College of Radiology) based guidelines. Those guidelines are posted on their websites. There are advanced imaging basics that all medical providers should know. And if they don't, they should consult with a specialist, radiologist or RBM clinical reviewer/medical director. There are many resources out there. And yes, the patient must also take responsibility to get educated about their health issue and the proper testing that accompanies it.
There is a shared responsibility that must take place among medical providers, radiologists, RBMs, health insurance companies and the patient when ordering advanced imaging to make sure it is the right test at the right time. No longer can an advanced imaging study be requested without regard for its safety and potential to improve patient outcome.