title: A Large State Medicaid Outpatient Advanced Imaging Utilization Management Program: Substantial Savings Without the Need for Denials.
abstract: A decade of rapidly rising outpatient advanced imaging utilization ended toward the end of the past decade, with slow growth since. This has been attributed to repetitive reimbursement cuts, medical radiation exposure concerns, increasing deductibles and patient copayments, and the influence of radiology benefit management companies. State Medicaid programs have been reluctant to institute radiology benefit management preauthorization programs since the time burden for obtaining test approval could cause providers to drop out. Also, these patients may lack the knowledge to appeal denials, and medically necessary tests could be denied with adverse outcomes. Little data exist demonstrating the efficacy of such programs in decreasing utilization and cost. We report a 2-year experience with an outpatient advanced imaging prior notification program for a large state Medicaid fee-for-service population. The program did not allow any denials, but nevertheless the data reveal a large, durable decrease in advanced imaging utilization and cost.
authors.affiliation: St. Peter's Hospital, Albany, NY, USA rrapopor@nycap.rr.com.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Rapoport
authors.affiliation: Thomas Jefferson University, Philadelphia, PA, USA.
authors.forename: Laurence
authors.initials: L
authors.lastname: Parker
authors.affiliation: Thomas Jefferson University, Philadelphia, PA, USA.
authors.forename: David C
authors.initials: DC
authors.lastname: Levin
authors.affiliation: Regence BlueCross BlueShield of Utah, Salt Lake City, UT, USA.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Hiatt
mesh_terms: D017046:Cost Savings / Q000191:economics / Q000379:methods*; D003952:Diagnostic Imaging / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage / Q000191:economics / Q000458:organization & administration; D008329:Managed Care Programs / Q000191:economics / Q000458:organization & administration*; D008484:Medicaid / Q000191:economics / Q000458:organization & administration*; D012189:Retrospective Studies; D014481:United States
keywords: CT; MRI; Medicaid; health insurance; radiology benefits manager; utilization