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    NIA Presentation NIA Presentation Presentation Transcript

    • Florida Hospital Advisory Panel BCBSF Diagnostic Imaging Program September 11, 2008
    • 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
    • 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)
      • Beever C, Karbe M. The cost of medical technologies: maximizing the value of innovation. Booz Allen Hamilton.
      • Journal of the American College of Radiology
      • South Florida Business Journal, Aug 2008.
    • 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)
      • 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.
      • South Florida Business Journal, Aug 2008.
      • Harvard University, Center for Information Technology Leadership
    • 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
      • Semelka, R.C. “Radiation Risk from CT Scans: A Call for Patient-Focused Imaging,” from Medscape Radiology, 1/26/05
      • December 5, 2006, Ontario’s auditor general annual report
      • Verrilli DK. Design of a privileging program for diagnostic imaging: costs and implications for a large insurer in Massachusetts. Radiology.
    • Effective Radiation Dose from Diagnostic X-Ray, Single Exposure Source; Health Physics Society
    • 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)
    • 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
    • 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.
    • 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
    • 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
    • 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.
    • 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.
    • 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
    • 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
    • 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
    • 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