Vermont pilot program averts pre-auth for select spine MRIs

Two medical centers in Vermont kick off a new pilot program on May 1 that circumvents the onerous pre-authorization process by preapproving selected lumbar spine MRIs.

Under the new program, physicians who order a lumbar spine MRI from Rutland Regional Medical Center in Rutland and Porter Medical Center in Middlebury can have it automatically approved by the insurance company if the patient has Blue Cross Blue Shield of Vermont Exchange, fully insured MVP (excluding Medicare Advantage and self-insured plans administered by MVP Select Care Inc.) or Vermont Medicaid coverage. The MRI must also follow ACR Appropriateness Criteria.

Responding to a mandate from the state of Vermont, J.C. Biebuyck, MD, diagnostic radiologist at Rutland Regional Medical Center and member of the Vermont Radiology Society, worked with government officials, insurers and other radiologists for over a year and a half to build this program.

“It was a very eye-opening experience, I must admit, for a physician,” Biebuyck told in a phone interview. “We were involved in all the mechanizations of politics and how negotiations occur in central government. For [government officials], I think it was an equally eye-opening experience to have physicians at the table, because often times, physicians aren’t at the table and lots of decisions get made around us.”

Biebuyck said he wanted other CPT codes to be included in the pilot program as well, but the lumbar spine MRIs were what everyone could agree on. He also said that all applicable insurance companies were invited to participate, but the others all declined. Biebuyck thinks that could actually work in the program’s favor. 

“In some ways, the non-participation helped us,” Biebuyck said. “Now we have a study group. We have a group of people that we’re going to be studying who are involved with these insurance companies and we are also going to study those that require prior authorization. And we’re going to look at, ‘How much burden does that create on the primary care offices?’ ‘How much burden does that create for our institution?’ ‘How much of a delay in time getting studies is occurring for the different groups?’”

Biebuyck said this program would save both primary care physicians and radiologists a lot of time and a lot of headaches. The back-and-forth with insurance companies that takes place during authorization can sometimes take months, and when insurance companies say they won’t cover an exam, he often has to step in himself.

“I’m very vigilant,” Biebuyck said. “When a patient needs an MRI, I will call the insurance company. I get on the line, I escalate the claim. All insurance companies have that process, but that escalation takes a lot of time—it’s those hurdles that a lot of physicians don’t want to jump over. It just takes too much time.”

Biebuyck makes it clear that he does not mind getting involved and fighting for a patient, but the more time he spends discussing tests with insurance companies, the less time he spends communicating one-on-one with patients.

“The fundamental relationship is around the patient and his or her physician,” he said. “It’s not administrators, it’s not politicians and it’s certainly not insurance companies. When a patient comes to me for advice, he or she is asking me for my expertise.”

The impending CDS mandate

As this pilot program begins, a major change to the way physicians order exams is on the horizon. When President Obama signed H.R. 4302, the Protecting Access to Medicare Act of 2014, into law, it included a mandate that said, starting January 2017, physicians ordering advanced diagnostic imaging exams must first consult government-approved clinical decision support (CDS) software.

“[CDS] is truly the answer,” he said. “When someone is ordering an examination, an imbedded piece of software [initiates] a whole series of questions, and it helps outline whether a patient needs a study or not. In the end, the physicians can decide to go with the suggestion, call a radiologist or ignore the suggestion.”

The Vermont pilot program is committed to lasting at least six months, and there are plans for everyone involved to meet and analyze the data multiple times along the way. Biebuyck said that if the program is successful, he hopes more CPT codes can eventually get added.  

But how do those involved measure success? Biebuyck said they’ll look at three primary things: redundancy, time delays that patients and physicians experience waiting for authorization and physician-generated feedback.

That feedback will come from surveys every participating physician is asked to complete. Information about those surveys, along with a description of the entire program, was put into letters that were mailed off to hundreds of physicians who refer to either of the participating hospitals.

“The success of this pilot will depend on your willingness to provide up-to-date and accurate clinical information whenever ordering an MRI,” the letter said. “It is also essential you work closely with the Radiology Departments at Rutland Regional Medical Center and Porter Medical Center.”

Biebuyck likes to point out the three signatures at the end of the letter.

“What’s really neat about this letter is that it’s signed by three MDs,” he said. “It’s the government and the physicians in the state getting together and deciding what’s appropriate.”

To Biebuyck, that represents progress. Physicians stayed at the table, and the decision was made with them, not around them.