Radiology 3rd among specialties with heaviest prior authorization burden

Radiology is among the medical specialties with the highest rate of services subjected to prior authorization, according to a new large-scale analysis published Friday in JAMA Health Forum.

Experts from several notable institutions, including Harvard and CVS Health, reached their conclusions by analyzing coverage rules from a large Medicare Advantage insurer. They found wide variation among different types of physicians in how this extra check on utilization is applied.

Diagnostic radiology services landed at 91%, third behind the rates for radiation oncology (97%) and cardiology (93%).

These policies, however, do not apply in Medicare Part B, which pays for physician care, outpatient treatment and home health, among other costs. Out of nearly 6.5 million beneficiaries covered by this part of the federal payment program, 41% received at least one service per year that would have been subject to prior authorization under Medicare Advantage.

“There is almost no public data on how often prior authorization is required for medical services. This study shows what many radiologists probably already expect: that private insurers have instituted broad prior authorization policies, which often affect radiology services,” lead author Aaron Schwartz, MD, PhD, with the Department of Medical Ethics and Health Policy at the University of Pennsylvania’s Perelman School of Medicine, told Radiology Business. “There is also a big gap between how private insurers and traditional Medicare approaches this issue, though Medicare has taken steps to expand prior authorization in recent years,” he added.

To reach their conclusions, Schwartz and colleagues analyzed claims and enrollment data for a random 20% sample of Medicare fee-for-service beneficiaries treated in 2017. They measured the use of services that would have been subject to prior authorization in Part B, regardless of whether the request was approved or denied. Researchers also obtained proprietary prior authorization data from Aetna’s Medicare Advantage for the same year.

If the federal government applied the same rigorous utilization tactics as private insurers in Part B, 2.2 services per beneficiaries would fall under prior authorization annually, including 0.8 in radiology. In dollar terms, each beneficiary in Part B paid an average of $1,661 (or $270 for radiology) per person, which would have fallen under PA policies in private pay. Diagnostic radiology was the largest source of nondrug expenditures at 16%.

“The spending associated with prior authorization services was concentrated in particular clinical domains. Accordingly, prior authorization services varied substantially across clinician specialty, suggesting an uneven administrative burden for different specialties and institutions,” the authors noted. “Developing and applying appropriateness criteria may also be more complex for nondrug services. Although assigning appropriateness criteria to imaging studies proved challenging in a recent Medicare demonstration project, Aetna has broad prior authorization requirements for outpatient radiology,” they added later.

You can read much more about their analysis in JAMA Health Forum here.

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