One of the primary complaints providers often have about radiology benefits management programs (RBMs) is that they have the power to deny coverage to a patient in need. But what if the RBM is unable to deny coverage?

A recent study published by Medical Care Research and Review found that use of a non-denial RBM program resulted in a significant, sustained reduction in outpatient advanced imaging utilization for a Medicaid fee-for-service population.

Robert J. Rapoport, MD, St. Peter’s Hospital department of medical imaging, and colleagues examined three years of utilization data, including one year prior to RBM program implementation. Three of the study’s four authors, including Rapoport, declared current or past ties to HealthHelp, the Texas-based RBM program being studied.

HealthHelp’s approach included prior notification and education, but no denials of coverage. Requests went through three levels: call center employees with six weeks of training, nurses, and radiologists. The first two levels—call center employees and nurses—had the choice of either issuing an approval number and ending the process or declining approval and moving the request to the next level.

If requests reached the third level, the radiologist either approved of the exam or recommended another course of action. However, things didn’t end there.

“If the original test was still wanted, the radiologist and ordering clinician 'agreed to disagree,' and an approval number was issued,” the authors wrote. “This was considered an educational process and there were never any denials. Additionally, at each level, if the company representative suggested a more appropriate test based on its appropriateness criteria, the provider had the opportunity to switch to the recommended test.”

The numbers show that HealthHelp’s formula for success was largely effective. CT utilization dropped from 57 per 1,000 members prior to implementation to 21.5 per 1,000 members two years after implementation. (The authors do credit one third of the decline in CT utilization to the bundling of certain CT codes on Jan. 1, 2011.)

Similarly, MRI utilization dropped from 43.8 per 1,000 to 21 per 1,000 in that same timeframe. Cardiac nuclear medicine utilization changed from 13 to 8, and PET utilization changed from 8.6 to 3.4.

Overall, the authors estimate the program saved more than $22 million.

Rapoport et al. wrote that there were four primary reasons that this method of RBM implementation was successful:

1. The sentinel effect: Performance improved when clinicians knew they were being evaluated.

2. The barrier effect: Prior approval, even if never resulting in denial, was still a barrier for referring clinicians to cross, which limited some exams from being requested.

3. Education: Providers were sent education material on the appropriateness criteria being used by the RBM program, as well as information on how the process would work from beginning to end.

4. More comfortable, receptive referring clinicians: Since denial was off the table, clinicians felt more comfortable considering recommendations made by the call center employees, nurses, and radiologists on staff.

The authors concluded that more RBM programs might consider following a non-denial protocol.

“The indications for and types of advanced imaging tests are the same nationwide, and there are many similarities between our state’s Medicaid program and others throughout the country, such as serving similar lower economic status patients and having unmanaged radiology FFS programs,” the authors wrote. “Therefore, in an era of growing Medicaid costs and expansion, state budget constraints, and concern about unnecessary medical radiation, state governments may wish to consider a similar program.”