Wellpoint to Use Watson Supercomputer

I recently came across a very interesting story by the Los Angeles Times that reports, “Watson, which defeated 'Jeopardy!' champions, will diagnose medical illness and, within seconds, recommend treatment options for patients. The insurer says the computer will help doctors, not replace them.”

Watson is to debut at cancer centers early next year. The article quotes Wellpoint as saying, “Watson will not be used to make decisions about reimbursing patients or doctors for the cost of treatments. But the system will eventually tell doctors what medical therapies and drugs are covered by patient's policies.”

It seems to me that if Wellpoint needs to specifically tell us that Watson will not be used to make decisions about reimbursing patients or doctors for the cost of treatments, then somehow, someway it probably will be. I hope I am wrong.

My hope is, Watson within all that circuitry and data, finds a cure for cancer. That lives will be restored. Hope will be restored. And, a mega-healthcare giant will share that knowledge for the good of the entire world. Oh, sorry. I am dreaming again....

Hitting a Brick Wall

Have you ever dealt with someone who would not compromise or budge to help you? This recently happened to me. Even though it made me very angry and frustrated, it taught me a valuable lesson. There are going to be times in our professional and personal lives when someone is not going to work with you, no matter what you do. When this happens, there are things you can do.

1. Walk away from the situation for awhile. Give yourself time to think about what can be done.

2. Don't argue with them. It just makes the situation worse. At this point, they are not going to be reasonable anyway.

3. Don't take it personally. There are going to be people out there who will not see things your way no matter what.

4. And if all else fails, go along with what has to be done. Put it behind you and move on.

When I was a clinical reviewer, there were times when I had to follow my company's guidelines in order to precertify a radiology test. If I didn't, I faced consequences, perhaps jeopardizing my job. But I treated each caller with respect, even though they would sometimes be very frustrated and angry. For me, it would always come down to the patient. I would imagine that every patient could be one of my loved ones. That helped me to be empathetic. It helped me to compromise and find other solutions. Because, I didn't want to be someone else's brick wall.

AMA Survey from 2010 Still Relevant Today

I was searching through some of my old articles on prior authorization/precertification for radiological studies and found this article in 2010 from AMA pertaining to RBMs (Radiology Benefit Managers). As I was reading through the article, the same issues are still relevant today. What struck me was the statistic that 1/3 of physicians experience a 20% rejection rate on their first request for prior authorization of tests and procedures. As a former senior nurse reviewer for one of the largest radiology benefit managers in the country, I can attest this statistic is true. The reason for this is simple. Most callers, specifically medical office staff requesting prior authorization were not prepared to give clinical information or the clinical provided was incomplete. Most people reading the AMA article would think, "Well, the insurance company is just denying them". No, that is not true.  Speaking with medical office staff on the phone, I witnessed this day after day. And I would think to myself, someone needs to teach them how to do this! Of course, that is where my idea of becoming a nurse consultant began.
Yes, the prior authorization process is frustrating. Frustrating for the nurse reviewer and the medical office staff when the clinical given is not sufficient to approve the test/procedure. But there is a solution; train medical office staff how to properly and efficiently obtain prior authorization for advanced imaging.

Clinical Decision Support or Prior Authorization?

Douglas Tardio, CEO of CareCore National, recently wrote an article, A Case for Prior Authorization of Imaging Services, discussing the pros and cons of CDS (Clinical Decision Support) versus Prior Authorization. As CEO of one of the largest RBMs (Radiology Benefit Managers) in the country, it is not surprising Mr. Tardio would end up siding with prior authorization.

While I am not a big fan of prior authorization nor am I on the CDS bandwagon, he makes a valid point. Mr. Tardio states that with both approaches, "data comes from vast archives of patient outcomes, clinical trials and other scientific data, eliminating the guesswork about how best to address the clinical needs of a patient." Most RBMs and CDS software systems use ACR (American College of Radiology) guidelines as the basis for their criteria.

Mr. Tardio describes the benefit of prior authorization as, it "ensures that the patient receives the appropriate test based on their unique medical history and situation, physicians subject to prior authorization are only reimbursed for services that are deemed medically necessary based on very specific evidence-based pathway criteria." In other words, the health insurance company will not pay for advanced imaging that does not meet "very specific evidence-based pathway criteria". The last time I looked (today, actually), ACR has guidelines, not "very specific evidence-based pathway criteria." So who develops this "very specific evidence-based criteria"? Health insurance companies and radiology benefit managers do.

The second and last benefit of prior authorization, Mr. Tardio states, "Prior authorization for radiology alone, on average, can reduce health care costs by more than $60 per insured each year ($60 million/year for a million-member health plan) while reducing patient exposure to unnecessary radiation from inappropriate diagnostic testing. Okay, for arguments sake, let's go with the savings of $60 per insured per year figure. I would bet the farm that $60 is not going to be passed on to the patient. And, it is highly likely the medical office pays out a large portion of that $60 per month per insured on health insurance administrative costs.

In regards to the cons of CDS, Mr. Tardio states, "Criticism of prior authorization systems tends to revolve around the fact that physicians must obtain authorization via phone or online, which critics say can be more time consuming than decision support systems. In fact, the tools used in both systems are virtually identical — and equally time-consuming from a pure administration standpoint." Yes, it is a known fact, they are both equally time consuming. That is the reason most medical offices hire staff to specifically perform prior authorization. As with the Prior Authorization process, the CDS process will also require someone (aka medical office staff) to input the clinical to spew out a rating of appropriate versus less appropriate. One of the differences with CDS is a medical office staff person will not have to wait on hold for the next available representative and the software is easily accessible to them in their own office. Another difference is if the clinical does not match evidence-based guidelines, the physician can choose an alternate study or proceed with the study he/she requested.

In my opinion, there has to be a hybrid system, a cross between CDS and the RBM process. Of course, the system has to use evidence-based medical guidelines not strict pathway criteria designed by health insurance companies and radiology benefit managers. It has to be easy to use by all medical staff, hold the physician accountable and ensure the patient gets the right test at the right time. The CDS system is a good model. To use it efficiently, there should be a discussion with a radiologist or specialist in that field if the CDS system offers an alternative study and the physician declines. I don't believe we can drive down the costs of advanced imaging or health care in general by giving physicians carte blanche when it comes to advanced imaging.

In my experience as a former senior nurse reviewer, most often physicians do request appropriate advanced imaging. But with all the changes in technology and usage, advanced imaging is rapidly changing. It is very difficult for any medical provider to keep up to date on the current uses for advanced imaging. It's a given, we are all going to have to live with the regulation of advanced imaging in order to curb health care costs. I choose CDS with a little tweaking.

Radiology Benefit Managers are Shifting Cost!

The Journal of the American College of Radiology reported in June 2011, "It is estimated that 28% ($182,066/$640,263) of the projected RBM-related savings are shifted to providers." Ask any medical provider and I am sure they will tell you that this was no surprise to them. The burden of cost to hire and train staff to perform prior authorization for advanced imaging is placed on the medical provider. This cost is even shifted to radiology centers. If the test or procedure scheduled did not have prior authorization or a test requires upgrading, it is up to the facility to obtain that prior authorization. We all know it is extremely difficult to get reimbursement for a test or procedure for which prior authorization was not obtained first. And what about the cost to the patient in the delay of treatment or denial of a test or procedure? All costs that someone had to burden.

So how do you cut those costs that you have now been burdened with? You train your staff to become better informed about the prior authorization process, become more efficient in the way you perform prior authorizations and properly train your staff to provide accurate clinical to the RBM to reduce delays and denials.

Appropriateness in Advanced Imaging

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.

Will RBMs Go Away?

I was recently asked if I thought 'middlemen' like CareCore National will go away? And the answer is "no".

The reason for this is simple. Medicare and Medicaid costs are putting great strains on state and federal budgets. Health insurance companies are making smaller profits now because of health care reform. Costs have to be contained somewhere. Advanced imaging is expensive. If you look at the health care cost pie, advanced imaging is the second highest expense behind prescription drugs.

In 2009, Med Solutions stated 90% of health insurance companies use RBMs. They also stated, "Radiology Benefit Management Could Save Medicare Up To $18 Billion Over 10 Years".  Like most RBMs, they proclaim their management of advanced imaging saves money. With RBMs already in place and saving money, it is highly unlikely they will go away. Add to the fact that Medicaid/Medicare costs is a highly charged political and economical issue, it is even more doubtful RBMs will go away. 

Yes, I believe RBMs save money for the actual imaging. But who pays the price? For one, medical offices, hospitals and radiology centers burden the cost of hiring staff to sort through the red tape in getting a study or procedure approved and following through until it gets paid. Second, the patient may have their study or procedure delayed or denied because of the red tape.

It can be frustrating, as the process for obtaining prior authorization (precertification) for advanced imaging is not transparent. Most office staff learn the prior authorization process as they go along. No one is teaching them, especially not the RBMs. And that can be costly to your bottom line and the patient.

If you would like a free consultation on how I can teach you or your staff to become more efficient at prior authorization for advanced imaging, email me at: randrbizassociates@gmail.com. I would love to talk with you! Terri

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.

Make Your Medical Office Staff More Efficient in 2010!

It is the end of the year, many medical offices are looking back at what went wrong and looking forward to what can be better for the new year. Healthcare is in reform. Everyone is waiting to see what changes will come about and when. That includes prior authorization/pre-certification for advanced imaging. For now, it is business as usual for the health insurance companies. In order for your patient to get that MRI, CT, PET scan or nuclear medicine study, your medical office staff will still have to obtain prior authorization/pre-certification. Is it going to be easier than last year? No. I suspect it will be more difficult in the future. And it will probably be one of the areas health insurance companies, Medicaid and Medicare will use to cut corners to contain cost. It is all about the bottom line you know! Well, what about your bottom line? Medical offices also need to be profitable. As you look at your bottom line for the past year, think about what you can do better this next year. If you could give your staff 25-50% more time to do other tasks, would that not be of benefit to you? The one-of-a-kind training program that I offer can reduce cost, staff frustration and improve patient outcomes by teaching your staff how to perform prior authorization more efficiently and confidently. By purchasing the training program before year end, you are also eligible for the tax write off.(IRS section 162, check with your tax advisor). Contact me today to get started! http://www.rosewoodconsulting.biz/

Happy New Year!

The Senate Has Passed the Health Care Bill....

The health care bill has passed the senate. Now we await the final revision of the bill and votes from the house and senate before the president can sign it into law. Then, the real questions will need to be answered. How are the health insurance companies going to react? President Obama has already placed additional wording into the bill that health insurance companies will not be allowed to raise premiums prior to the bill being enacted. We all know the health insurance companies are going to do whatever it takes to save their bottom line. We do not know what that will be yet but I am sure we will all know in due time.

In the meantime, are you confident your staff is prepared to handle precertifications (prior authorizations) for advanced radiology procedures? Are you experiencing delays or denials from health insurance companies for your prior authorizations of MRI, CT, PET scan and nuclear medicine scans? I can train your staff to be better prepared for what many are saying is going to be an increase in precertification/prior authorization for advanced imaging by health insurance companies. Visit my website for more details.

Healthcare Debate Continues!

What does this mean to you as a medical provider or medical office? It means that no one knows what the outcome will be for healthcare reform. In the meantime, it is business as usual for the health insurance companies. They are still requiring prior authorization (aka precertification) for radiological procedures(MRI, CT, PET scan, nuclear medicine studies). If you are still having problems with this process, contact us to start your training program today. Order by the end of the year and receive 45 days of follow-up consulting services instead of 30 days! Remember, this is also a great tax deduction for your medical office! (see IRS section 162 and your tax consultant for details)

Did you know?......

Did you know that a standard CT of the brain exposes the patient to an equivalent of 115 chest xrays? With radiation exposure errors in the recent headlines as noted in an article posted in the Wall Street Journal, More Patients Got Radiation Overdoses in CT Scans, it is the responsibility of the imaging facility to ensure the correct dose of radiation is being used. It is also the responsibility of the medical provider to weigh the risks of doing a CT vs an MRI or alternative study in the non-urgent setting.Check out the radiation equivalency chart link located on my website. It is a great tool to educate staff and medical providers as to the amount of radiation the patient is receiving.

New blog series called: "Did you know?"

For the next few blogs I will address some of the most common issues related to advanced imaging and the preauthorization of such studies in a non-urgent setting.
Did you know that an MRI brain without contrast is the preferred study for the sole complaint of worsening headaches in a patient without any underlying medical history? For a patient with cancer or a known brain tumor, the preferred study would be an MRI brain with or with/without contrast. Of course, if an MRI is contraindicated, CT would be the preferred study.
Many medical providers choose CT because they think it is cheaper and will be easily approved by the insurance company/advanced imaging management company. MRI can actually be cheaper in the long run. Specifically, when a CT is done and it comes back negative. If the patient continues to have symptoms an MRI is ordered anyway. Most importantly, MRI is the preferred study for neural imaging. Dr. Robert B. Daroff said at the annual meeting of the American Headache Society, "sensitivity of an MRI scan far exceeds that of CT scans for all neurologic conditions, not just headache".
Medical providers should think twice about ordering a CT vs an MRI for nonurgent conditions. Not only can an MRI save money in the long run, it prevents radiation exposure and gives better results.

I remember....

I remember at the end of the day when working with medical offices, talking with them on the phone and collecting clinical information for prior authorization, I would think to myself how I would love to be able to teach them what I know. Hearing the frustration and stress in their voices and their words, I wish I could show them where to look for information, how to read the doctor's note, what the labs mean, why ordering an MRI brain is better than ordering a CT scan for headaches. All this has now come true. I am teaching staff all of these things and more! Being a nurse, what a great way for me to help patients by teaching medical staff.
If you are feeling frustrated and stressed out with this process, contact me at http://www.rosewoodconsulting.biz/
There is no obligation and no high pressure sales pitch.

I expect to pass through life but once. If therefore, there be any kindness I can show, or any good thing I can do to any fellow being, let me do it now, and not defer or neglect it, as I shall not pass this way again. ~William Penn

Medical Office Staff Are Stressed Out!

Seems like everyone is so stressed out these days! Today medical office staff are overworked and tasked with new duties for which there is minimal training. I know, I have been there, working in many medical offices over the past 10 years. On the job training was the rule, not the exception. And for the past 5 years as a nurse reviewer for one of the largest advanced imaging management companies, I have heard from many medical office staff how stressful their days have become. Coordinating care with patients, doctors, insurance companies and other medical facilities all at one time can be extremely stressful. The University of Pittsburgh Medical Center writes,"studies show that stressful working conditions are actually associated with increased absenteeism, tardiness, and turnover--all of which have a negative effect on the bottom line." This is a serious problem. One of the ways stress can be reduced with the prior authorization process(aka predetermination) is by having proper training. Stop the stress and frustration associated with this process by viewing my website to see how I can help.
http://www.rosewoodconsulting.vpweb.com/