Transitioning from Denials to Endorsements: Toward a More Collaborative Approach to Utilization Management

 

Dr. Jeffrey Robinson and I will share the results of an interesting experiment on November 28 at the world’s largest medical meeting. At the annual meeting of the Radiological Society of North America in Chicago, we will present exciting evidence to support the seemingly counterintuitive claim that a collaborative, nondictatorial approach to utilization management may be as effective as the more traditional method of issuing denials.

 

Background: Rigid pre-authorization methods, in which payment is denied if medical necessity for a requested exam is not sufficiently demonstrated, traditionally have been used to control utilization of advanced diagnostic imaging procedures. Such an approach often leads to acrimony between provider and payer, as well as increased costs and delays related to a required appeals process.

 

Our Experiment: Dr. Robinson and I looked at what happened before and after an interesting transition.  A major health insurance plan transitioned from denial-based pre-authorization to a more collaborative one in four different metropolitan areas. Under the new utilization management system, if an exam request does not meet guidelines, it is assigned to a radiologist who calls the referring physician to discuss the particular situation. Free of the rigid constraints of the guidelines, they can consider the peculiarities of the individual patient and try to come to a consensus about the need for the requested exam. Possible outcomes of the conversation are consensus (in which the radiologist and provider agree that the test is indicated), withdrawal (in which the provider agrees to withdraw the request), exam change (in which radiologist and provider agree that a different test is more appropriate), or no consensus (in which the radiologist and provider cannot agree). Formerly, in situations of no consensus, the exam was denied. Under the new paradigm, the exam is approved, and the lack of consensus noted.  (If a provider does not return the call of the radiologist, the exam is considered withdrawn after 48 hours.)

 

The Results: A retrospective review was undertaken in which requests for advanced diagnostic imaging (including CT, MR, PET, and cardiac nuclear medicine) for the first several months after the transition were compared to those from the same period a calendar year earlier. The surprise was that no significant change occurred. No statistically significant difference arose in any of the parameters evaluated between the two periods, including in the percentage of exams ultimately approved, as well as in the rates of withdrawal, exam change, and no consensus. It’s interesting that the withdrawal and exam change rates actually rose after the transition (albeit not to a statistically significant degree).

 

Bottom Line: Providers working in a collaborative environment in which the result of a disagreement is to yield to the treating clinician do not obtain a greater number of inappropriate imaging tests than the same providers working in an environment in which the payer retains the “final say.” Collaborative approaches to utilization management have the potential to "bend the cost curve" without the confrontational atmosphere traditionally associated with these efforts. Providers exhibited a greater (albeit statistically insignificant) tendency to be more receptive to radiologists’ suggestions (either for an exam change or withdrawal) without the threat of denial; transitioning from denials to a more collaborative approach to utilization management yields no compromised reduction in utilization.