Docs Recommend Fixing Peer-to-peer Prior Authorization Reviews to Rein in Problem Plaguing Radiology
By Marty Stempniak | June 17, 2021
Physicians are recommending revising peer-to-peer reviews between healthcare providers and insurers to help ease prior authorization burdens plaguing radiologists and other members of the profession.
Such P2P discussions around the medical necessity of imaging and other healthcare services usually take place between docs employed by insurance companies and by hospitals or other healthcare entities. But sometimes, the payer representative has little knowledge of the treatment under review, the American Medical Association said Tuesday.
To address this issue, the AMA House of Delegates wants insurer-employed docs to have clinical expertise in the disease under discussion, along with knowledge of corresponding evidence-based guidelines. Physicians additionally want insurance companies to make P2P prior authorizations actionable within 24 hours of the conversation.
“Delayed and disruptive treatment due to unnecessary and bureaucratic prior authorization requirements can have life-or-death consequences for patients—something we know from data and surveys of physicians,” AMA President Susan Bailey, MD, said in a statement. “P2P reviews are another burdensome layer insurers are increasingly using without justification, and the peer reviewers are often unqualified to assess the need for services for a patient for whom they have minimal information and to whom they have never spoken or evaluated.”
Diagnostic radiology faces one of the heaviest prior authorization burdens in medicine, according to a recent study, behind only radiation oncology and cardiology. Roughly 91% of radiology services are subject to these extra reviews, the JAMA analysis of private claims found. As such, radiologists and other specialists recently lobbied the feds to pass legislation loosening red tape in Medicare Advantage.
AMA and its House of Delegates also want insurers to follow the guidance of medical societies like the American College of Radiology “where applicable.” They’re calling for a temporary suspension of all prior authorization requirements during a declared public health emergency. And the nation’s largest physician lobbying group is pushing payers not to require authorization for any medically necessary procedure related or incidental to an already-approved operation or other course of treatment.
Radiologists can read more about the new AMA policy, and contribute their own prior authorization stories at FixPriorAuth.org.
To read more, go to Radiology Business.
Nation’s Largest Insurer Wants 55% of Radiology Services Delivered at Freestanding Sites by 2030
By Marty Stempniak | June 15, 2021
The nation’s largest commercial health insurer wants its members to receive at least 55% of their radiology services at freestanding imaging centers by 2030.
UnitedHealth Group announced the commitment on Tuesday, June 15, as part of its 2020 Sustainability Report, aimed at expanding access, reducing costs and bolstering outcomes. The Minnetonka, Minnesota-based health giant also wants 55% of outpatient surgeries delivered outside of hospitals by the end of the 2020s.
“Medical care provided at sites of care that meet quality and cost-efficiency criteria predictably leads to better health outcomes at a lower cost for the consumer,” UnitedHealth said in its 64-page report. “In particular, ambulatory surgery centers and stand-alone imaging centers frequently provide the same or better quality care at a lower cost compared to a hospital.”
UnitedHealth estimated that the average price for a routine diagnostic imaging at a hospital outpatient department can cost 165% more than the price of a test performed at a physician’s office or stand-alone center. The company has already made some inroads on this front, with 47% of radiology services and outpatient surgeries among its members delivered at freestanding sites as of 2019.
The insurer said it has made these gains by equipping referring physicians with shared decision-making tools to help patients select the best site for imaging services. UnitedHealth is also offering other digital tools to help beneficiaries “identify the care setting that best suits their medical and financial needs.” Shifting routine diagnostic imaging from outpatient hospital departments to stand-alone centers or doc offices could reduce U.S. healthcare spending by 62% and save consumers $300 per exam, the report claimed.
This is just the latest in a series of maneuvers by UnitedHealthcare and its parent UnitedHealth Group to reduce radiologist pay. Other actions include cutting health systems and doc groups out of its network, steering patients toward certain tests, and adding new prior authorization processes.
UnitedHealth’s plans cover some 70 million members, with policies offered in all 50 states. In 2019, the company recorded $13.8 billion in profits on revenue of $257.1 billion.
To read more, go to Radiology Business.
Why X-ray is Vanishing from Urgent Care Centers
By Alan Ayers | June 14, 2021
For years, I’ve heard urgent care operators gripe about the profitability of x-ray. In fact, I first wrote about this topic in 2013 in an article entitled “Understanding the Economics of Urgent Care Lab and X-Ray Services.”
The problem then, as of today, is that for urgent care centers, x-ray incurs significant capital investment in equipment and continual operating expense in the form of specialized personnel, inspections, overreads, and additional space.
For years, part of my role was to create a business case for upgrading analog x-ray to computed radiography (CR) or CR to digital radiography … and my thesis almost always fell to a theoretical “we will lose business if we don’t invest.”
The point is that the return on investment of x-ray is very difficult to prove in urgent care, especially when “case rate” contracts reimburse a center at the same rate for all visits, regardless of services.
Today, I’m increasingly seeing the opening of more “limited scope” urgent care centers that do not provide x-ray, as well as conventional urgent care centers that aren’t staffing radiologic technologists (RTs) during off-hours.
Both are problematic. The latter is inconsistent with payor and contract expectations for “urgent care,” and both reinforce a lesser scope of care, making it difficult for all centers to attain higher reimbursement.
X-ray is a challenge for urgent care operators for multiple reasons.
To read more, go to Aunt Minnie.
UnitedHealthcare Delays ED Policy; ACR says ‘Flawed’ Rule May Violate Patient Protection Laws
By Matt O’Connor | June 11, 2021
UnitedHealthcare is delaying a new policy that would have denied coverage for some emergency services, including imaging, following intense backlash from patient, doctor and hospital groups.
The insurance giant said Thursday that it would pause implementation of the controversial policy until “at least the end of the national public health emergency period.” Initially, UHC was set to kick-start the rule on July 1, eliminating reimbursement for non-emergency trips to the ED.
A number of organizations have quickly rebuked the insurer, calling for a complete reversal. The American College of Radiology gave its own criticism of the “flawed” policy late Thursday in an email statement to Health Imaging.
“The new UnitedHealthcare emergency department payment policy shifts the responsibility for determining the difference between an emergent or non-emergent situation to the patient before any clinical evaluation,” an ACR spokesperson said, adding such coverage denials may also violate federal patient protection laws, namely the prudent layperson standard.
In a perspective shared Friday, American Hospital Association CEO Rick Pollack said the policy would have a “chilling effect,” scaring people from seeking the care they believe they need.
The hospital advocate warned it would continue to pressure UnitedHealthcare and other commercial health insurers on actions taken against patient health.
“UnitedHealthcare’s action offers a temporary reprieve for patients, and we urge its full and permanent reversal,” Pollack wrote June 11. “There is no justification for these restrictions now or after the public health emergency.”
To read more, go to Heath Imaging.
HHS Gives Providers Flexibility on Spending COVID-19 Relief, Funds, Updates Reporting Requirements
By Robert King | June 11, 2021
The Department of Health and Human Services (HHS) left intact a June 30 deadline for providers to use COVID-19 relief funds they accrued from April 10 through June 30 of 2020 after a major push from hospital groups asking for more time.
But the agency did give more flexibility for providers to spend funding if they got it after June 30, 2020.
The Health Resources and Services Administration (HRSA) released revised reporting requirements Friday for the Provider Relief Fund (PRF), which helped providers offset major revenue shortfalls that emerged due to the COVID-19 pandemic.
“These updated requirements reflect our focus on giving providers equitable amounts of time for use of these funds, maintaining effective safeguards for taxpayer dollars, and incorporating feedback from providers requesting more flexibility and clarity about PRF reporting,” said HRSA acting Administrator Diana Espinosa in a statement.
The agency set up new deadlines for when providers must use funding based on when they got it, rather than the June 30 deadline for all payments to be expended.
Any money a provider received from July 1 through Dec. 31, 2020, must be expended by Dec. 31, 2021.
Providers that got money from Jan. 1, 2021, through June 30, 2021, have until June 30 of next year to fully use it. Any funding received from July 1, 2021, through Dec. 31, 2021, has to be spent by Dec. 31, 2022, according to HRSA.
The agency made several other key updates to the reporting requirements for the funding, including requiring that nursing homes now report information to HRSA on how they are using the money.
Recipients are also now required to report for each payment received period where they got one or more payments exceeding $10,000. This is a change from $10,000 cumulatively across all PRF payments, HRSA said.
The agency added that reporting requirements don’t apply to the Rural Health Clinic COVID-19 Testing Program nor the HRSA uninsured program or COVID-19 coverage assistance funds.
A reporting portal will be open to providers to submit information starting July 1.
To read more, go to Fierce Healthcare.