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  • 04.26.12

    PATIENT ADVOCATE FOUNDATION STUDY DOCUMENTS IMPACT OF INSURANCE COVERAGE DENIALS ON PATIENT ACCESS TO MEDICAL IMAGING

    Data Show 90 Percent of Reversed Denials for Imaging Services Were Covered in Health Plan Language

    Washington, D.C. – Today the Access to Medical Imaging Coalition (AMIC) applauds the Patient Advocate Foundation (PAF) for its report that documents the impact of health coverage denials on patients seeking medical imaging exams. The internal case management data released by PAF show that insurance coverage denials to patients seeking critical imaging services have doubled over the last four years, while 90 percent of the reversed denials for imaging services were actually covered in health plan language. Moreover, 81 percent of the insurance denials for imaging procedures were due to prior authorization programs.

    “This report shines light once again on the detrimental impact of artificial barriers to patient access to life-saving medical imaging services, including timely diagnosis and treatment of cancer and other debilitating disease states,” said Tim Trysla, executive director of AMIC. “Personal health care decisions should be made between patients and their physicians, not by a bureaucratic go-between whose primary interest is cost-cutting. Instead of mitigating utilization of life-saving technologies, policymakers should seek evidence-based, physician-developed appropriateness criteria to guide the proper use of imaging services and ensure patient access to the right scan at the right time.”

    The retrospective analysis of internal case data by PAF, a patient advocacy organization dedicated to helping patients with cancer and other serious health conditions access the care they need, examined health insurance coverage denials for medical imaging services. Between 2007 and 2011, 4,360 patients contacted PAF regarding insurance denials for imaging procedures. Of these, 90 percent of reversed insurance coverage denials were in fact covered by the patient’s health plan, and 81 percent of the denials were due to prior authorization programs. On average, PAF’s professional case managers required 15.4 contacts per patient case to resolve the imaging issue, meaning it took on average more than 15 phone calls, letters or emails to determine why the imaging test was being denied coverage.

    Meanwhile, there has been no scientific, peer-reviewed research on the safety, efficacy or impact on administrative costs of radiology benefits managers (RBMs). The PAF study comes on the heels of MedPAC’s annual March report to Congress which acknowledged a recent downward trend in Medicare spending and utilization on medical imaging procedures, reaffirming its December 2011 statement that per-beneficiary use of imaging services declined by 2.5 percent in 2010. A June 2011 study, “Radiology Benefit Managers: Cost Saving or Cost Shifting?”, published in the Journal of the American College of Radiology, examining the economic impact of prior-authorization programs uncovered hidden costs associated with radiology benefit managers (RBMs) and found that they actually shift costs onto referring physicians.

    In addition, a recent AMIC literature review found that policy proposals to adopt prior authorization for medical imaging would produce no meaningful cost savings. On the contrary, a prior authorization policy could cost insurers and the government more than it saves, while imposing administrative burdens and shifting costs to physician practices. In light of these findings, AMIC cautions that prior authorization by RBMs will only further obstruct patient access to diagnostic imaging services.

     

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