Best Practices: How the RBMs Score

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Growth in imaging utilization has led prior authorization (a 1980s health-plan strategy) to be applied to advanced imaging services. RBMs have developed increasingly complex programs to reduce imaging expenses through utilization management, credentialing, channeling to lower-cost providers, and network contracting. Five competitors dominate this marketplace: American Imaging Management (AIM®), Inc (Deerfield, Illinois); CareCore National (Bluffton, South Carolina); HealthHelp® (Houston, Texas); MedSolutions (Franklin, Tennessee); and National Imaging Associates (NIA)/Magellan Health Services, Inc (Columbia, Maryland). By 2009, these companies managed utilization for almost 100 million US covered lives.¹ Today, they hope to expand into the Medicaid and Medicare programs. RBMs have caused radiology to experience declines in volume and increases in administrative costs. In response, the ACR and the RBMA developed the best-practice clinical, administrative, and transparency guidelines for RBMs in 2009 and updated them in 2011.² As much as 28% of savings attributed to RBMs could be shifted to providers, 3 and the overall value of RBMs to imaging providers, referrers, and the medical community has been questioned (with speculation that RBMs could increase total health-care costs through denial of appropriate and necessary tests). The intended purposes of the ACR–RBMA guidelines were to provide standards for RBMs and establish a benchmark with which RBMs could be compared. AIM was the first to recognize this potential and benchmark itself against these standards (in 2010). The RBMA then determined that each RBM should have its compliance measured and scored. In order to minimize bias, the RBMA hired Fulcrum Strategies (Raleigh, North Carolina), an independent, third-party, physician-practice consulting company. Methods The RBMA’s Payor Relations Committee (PRC) created a survey questionnaire that incorporated the ACR–RBMA guidelines and was divided into clinical, administrative, and transparency topic sections. Fulcrum Strategies and the PRC then developed a scoring system for the questionnaire, based on feedback from RBMA members and the RBMs. Points were awarded based on the assigned weight of each standard. The weighting was determined by collecting comments from the PRC and the RBMs about the perceived importance of each question (five to 15 points). This produced a scoring matrix with a maximum possible score of 300 points, with partial credit possible for each question. Fulcrum Strategies was engaged to complete the evaluation process in order to avoid any specific provider bias, promote the objectivity of the process, and make sure that one person would be scoring each RBM (to ensure consistency). Fulcrum Strategies sent the RBMs the questionnaire and scoring matrix, requesting that they score themselves. The RBMs were asked to provide additional relevant information, indicating which processes or policies were dictated by payors and what objective, verifiable information could be provided to support their responses. Each RBM filled out the scoring grid and returned it to Fulcrum Strategies, which then called to clarify any unclear responses, seek additional information, and obtain supplemental support. RBMs were awarded the total possible points for questions that fully met the standards and were awarded no points for questions that did not meet the standards at all. For questions where an RBM partially met the standard, partial points were awarded; for example, if an RBM provided information showing that a standard was followed 90% of the time, it would receive 90% of the possible points for that question. Once the process was completed, Fulcrum Strategies assigned a score to each RBM. In order to obtain a balanced representation (given current business exigencies and the regulatory environment), the RBMA then sent the same survey to a broad cross-section of imaging providers, including hospital-based or -owned imaging centers, radiologist-owned imaging centers, and IDTFs. Each provider surveyed operates multiple imaging locations, with a considerable volume of advanced imaging procedures (in a number of imaging modalities) being performed every year. Providers were instructed to score only RBMs with which they had direct interaction. They were also instructed to score only those questions with which they had direct experience. Fulcrum Strategies collected the providers’ responses, analyzed them, and tabulated