Radiology Benefit Management Programs: Who Benefits?

John C. Hayes


August 15, 2011

In This Article

What's the Best Way to Rein In Inappropriate Imaging Use?

Among the points made in the JACR study was that a 2008 report by the Government Accountability Office recommended that Medicare explore the use of prior authorization to manage use of imaging services.[2]A 2010 report by the Medicare Payment Advisory Commission, however, did not endorse the strategy because the expected benefits would not outweigh administrative costs.[3]

"From a policy point of view, it's interesting that we are discussing implementing this [RBM] program without any information on how it works," Lee said. "In an era of evidence-based medicine and comparative effectiveness research, it's curious to me that this sort of decision threshold does not apply to the use of radiology benefit managers."

According to Ryan, the case for prior authorization from RBMs has already been made through their widespread adoption. "The health plans do their own economic review -- the RBMs report on a monthly, quarterly, and annual basis back to their clients," Ryan said. "The health plans don't undertake these programs lightly. They are not interested in putting in place programs that are not well-appreciated by providers unless there is a substantial, meaningful reason to do so.

"The truth of the matter is that if physicians practiced in a very disciplined way, took their time, considered all the aspects, and didn't succumb to the pressures I described, we wouldn't be in business. Every time a call came in it would get approved, and in about 6 months the healthcare companies would throw out all the RBMs," Ryan said.

Lee contends that an alternative to RBMs is computerized clinical decision support, a system that processes requests for imaging studies and advises the requesting physician whether the study he or she recommended is appropriate. "These systems have been proven to reduce utilization in studies, and from the perspective of my paper they dramatically reduce cost shifts to both payer and provider," Lee said.

Because there is no appeal process in the computerized decision-support world, all of those costs disappear, he said. Another advantage is that physicians moving outside the recommended clinical procedure need to have a good reason and defend it in the medical record.

Ryan, however, maintains there still needs to be a "cop on the beat" in the form of the RBMs that require prior approval, because without them, it's too easy to slip into old habits and take the easy way out. "These kinds of tools are put in place to get good results, quality results, and consistency measured against accepted standards," he said.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.