Florida Hospital Advisory Panel

BCBSF Diagnostic Imaging Program

September 11, 2008

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Discussion Guide Outline

• Diagnostic Imaging Issues• Cost and Use

• Quality and Safety

• Value and Benefits

• Performance Results

• National Imaging Associates (NIA)

• BCBSF Medical Necessity Reviews• Policy

• Process

• Supporting Information

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Why Manage Diagnostic Imaging?Cost and Use

• Diagnostic imaging fastest growing component of health care

technology cost growth.(1)

• Diagnostic imaging costs are growing at 18-20% annually, approaching $100 billion per year (prescription drug cost growth 6-8%). (1)

• Total number of imaging procedures increased 40% from 2000-2005,

and projected to increase another 26% by 2008. (2)

• GAO reports Medicare spending for advanced imaging doubled from

2000-2006. (3)

• GAO reports imaging spending per Florida Medicare beneficiaries exceeded all other states in 2006. (3)

(1) Beever C, Karbe M. The cost of medical technologies: maximizing the value of innovation. Booz Allen Hamilton.

(2) Journal of the American College of Radiology

(3) South Florida Business Journal, Aug 2008.

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Why Manage Diagnostic Imaging?Cost and Use (continued)

• Physician ownership interest in imaging facilities and equipment

• Physicians who own imaging equipment 2X-7X more likely to order imaging test (1)

• Physicians referrals for MRI to non-radiologist site of service from

1998-2005 increased 10 fold for Florida Medicare patients (2)

• 20% of hospital radiology exams are duplicates, which represent approximately $20 billion a year in wasted spending nationwide (3)

• Defensive Medicine - - 59% of physicians said they ordered more

diagnostic tests than were medically indicated (Harvard School of

Public Health survey of six specialties considered to be at high risk

of litigation)(1) New England Journal of Medicine, Hillman B., Joseph C, Mabry M., The frequency and costs of diagnostic imaging in

office practice: a comparison of self-referring and radiologist-referring physicians.

(2) South Florida Business Journal, Aug 2008.

(3) Harvard University, Center for Information Technology Leadership

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Why Manage Diagnostic Imaging?Quality and Safety

• Patient’s radiation dose from CT in is increasing - estimated to account

for 10% of diagnostic exams but over 60% of total effective radiation

dose (2)

• Inspection of over 1,000 outpatient imaging facilities revealed

numerous quality failures with 31% failing to meet established

standards of care (3)

• New England Journal of Medicine studies show…

• 1.5%-2% of cancers in U.S. may be attributable to radiation

from CT scans

• Imaging for low back pain offers little additional benefit(1) Semelka, R.C. “Radiation Risk from CT Scans: A Call for Patient-Focused Imaging,” from Medscape Radiology, 1/26/05

(2) December 5, 2006, Ontario’s auditor general annual report

(3) Verrilli DK. Design of a privileging program for diagnostic imaging: costs and implications for a large insurer in Massachusetts. Radiology.

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Effective Radiation Dose from Diagnostic X-Ray, Single Exposure

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Source; Health Physics Society

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Why Manage Diagnostic Imaging?Value and Benefits

• Enhance health care quality and safety

• Promote appropriate use of diagnostic imaging

• Encourage use of standards and evidence-based health guidelines

• Facilitate physician and patient awareness and education

• Support learning and transparency in health care

• Improve affordability of health care• All medical cost savings from diagnostic imaging management flows directly to customers (i.e., included in financial and actuarial

calculations of medical trend, experience adjustments, rates, pricing)

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Diagnostic Imaging Management - Results to Date

• BCBSF is observing favorable healthcare utilization trends…

• Decreases in unnecessary procedures, favorably impacting utilization

• Redirection to less intensive, but accurate diagnostic services, such as an IVP rather than pelvic CT for symptoms of kidney stones

• Favorable changes in physician decisions regarding diagnostic procedures to evaluate patient condition

• Accumulation of important data on appropriateness of physician

referrals

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National Imaging Associates, Inc. (NIA)

• BCBSF contracted with National Imaging Associates• Independent radiology management vendor

• Manages medical review for our members and providers.

• NIA• Leader in radiology benefits management• Serves more than 14 million members in 36 states• Touches more than 185,000 physicians• Manages over $2.5 billion in radiology expenses annually. • URAC accredited, NCQA certified, HIPAA compliant.• Provides both telephonic and online capabilities for pre-service determinations of medical necessity.• Expert Consultation by Board-Certified Radiologists. • Medical professionals handle cases requiring further discussion on a peer-to-peer consultative basis.

• This process insures peer-to-peer consultation when alternative care may be indicated.

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NIA Service, Support for Providers•Secure web site

•Knowledge resource

•contains the most advanced clinical guideline algorithms to support fast, accurate consultation process by collecting a minimum of information about the patient and his or her condition.

•New enhancement in April 2008 offers BCBSF physicians an interactive search feature to locate BCBSF specific medical coverage guidelines

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Services and Locations

Included Services

• Outpatient Diagnostic Imaging Services

• CT, CTA

• MRI, MRA

• PET Scans

• Nuclear Cardiology

Location

Included Places of Service

• Hospital outpatient

• Ambulatory surgical center

• Freestanding imaging center

• In-office use of physician-owned equipment

Not-included Places of Service

• Inpatient

• Emergency Room

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Diagnostic Imaging Medical Review Policy and Processes

• BCBSF uses different processes for determining medical necessity.

• These differences are driven by our member’s benefit plan:

• BlueCare (HMO) has a pre-service authorization requirement

• BlueOptions (NetworkBlue) requires prior approval if provider is a NetworkBlue physician or IDTC. Hospitals are

not required to obtain a prior approval - VPCR is encouraged. If a prior approval is not obtained, claim will hold for medical necessity determination.

• BlueChoice (our classic PPO- FEP and State of Florida Employee Group) requires medical necessity review after service is provided.

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Pre-Service Authorization and Voluntary Pre-service Coverage Review

(VPCR) Process

• NIA contacted via internet or phone to request pre-service review for advanced imaging study

• NIA renders decision based on information provided – evaluations tiered based on complexity (service reps, nurses,

radiologists)

• 60% answer & response is immediate

• Remaining 40% requires review of clinical documentation

• BCBSF loads authorization in our claims processing system to auto-adjudicate claim.

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Pre-Service Review Process-continued

• NIA communicates a pended or denied decision to ordering

physician and to member

• If pended, ordering physician must submit additional clinical

information as defined by NIA

• If true denial, and is not a Blue Choice PPO contract, member

or physician may file appeal using BCBSF appeal process

• VPCR decision for a Blue Choice PPO contract, an advanced

imaging claim denied for medical necessity will follow the

standard member appeal process.

• Provider submits claim and claim is paid if meets medical necessity determination and is a covered benefit

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BlueChoice: Post-service Review

• If VPCR not obtained, advanced imaging claim will hold for review

• Claim information electronically sent to NIA

• NIA determines medical necessity based on submitted clinicals (member program design requires this)

• NIA is required to determine decision within 5 days.

• If adequate clinicals not received by NIA, NIA communicates,

“Unable to determine medical necessity” to BCBSF

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BlueChoice-Post-service Review

• BCBSF adjudicates claim as rejected/contested claim

under SB 46E

• NIA will reopen case upon receipt of clinicals

• NIA communicates final determination of medical necessity

to BCBSF

• BCBSF auto “reopens” claim and finalizes claim adjudication

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BCBSF Next Steps

• Educate members regarding diagnostic imaging safety and

quality concerns

• Partner with members to ask appropriate questions before an

imaging exam

• Continuous Improvement of program processes

• Move to next level of management

• Data will lead to ongoing management of

pertinent procedures and physicians

• Transparency of facility quality