PURPOSE: Seeking to control advanced diagnostic imaging costs, health insurance plans have instituted broad-based utilization management systems. Most processes ultimately contain denial provisions, meaning that the health plans will refuse to pay for requested studies if performed. The aim of this analysis was to determine whether removal of a denial provision would result in increased utilization of imaging services. METHODS: A major US health plan used a no-denial preauthorization system in all but 4 geographic markets for all CT, MRI, PET, and nuclear cardiac imaging studies, constituting the experimental group. This study consisted of a retrospective review of 247,117 advanced imaging requests 21 months before and 16 months after the elimination of the denial provision in the experimental group. A matched population with no such change in the review process served as the control group. Population-normalized utilization rates were measured for both pooled groups before and after the change. RESULTS: Utilization decreased slightly more in the experimental group than in the control group (-0.10 requests per 1,000 covered lives; 95% confidence interval, -0.20 to 0.00; P = .050) after elimination of the denial provision. The rates of request approval, examination modification, withdrawal, and no consensus after peer-to-peer consultation did not significantly change. CONCLUSIONS: Eliminating denial provisions in utilization management for advanced diagnostic imaging does not result in increased utilization of such imaging.
PURPOSE: Seeking to control advanced diagnostic imaging costs, health insurance plans have instituted broad-based utilization management systems. Most processes ultimately contain denial provisions, meaning that the health plans will refuse to pay for requested studies if performed. The aim of this analysis was to determine whether removal of a denial provision would result in increased utilization of imaging services. METHODS: A major US health plan used a no-denial preauthorization system in all but 4 geographic markets for all CT, MRI, PET, and nuclear cardiac imaging studies, constituting the experimental group. This study consisted of a retrospective review of 247,117 advanced imaging requests 21 months before and 16 months after the elimination of the denial provision in the experimental group. A matched population with no such change in the review process served as the control group. Population-normalized utilization rates were measured for both pooled groups before and after the change. RESULTS: Utilization decreased slightly more in the experimental group than in the control group (-0.10 requests per 1,000 covered lives; 95% confidence interval, -0.20 to 0.00; P = .050) after elimination of the denial provision. The rates of request approval, examination modification, withdrawal, and no consensus after peer-to-peer consultation did not significantly change. CONCLUSIONS: Eliminating denial provisions in utilization management for advanced diagnostic imaging does not result in increased utilization of such imaging.
Authors: Adam C Powell; David C Levin; Erin M Kren; Roy A Beveridge; James W Long; Amit K Gupta Journal: Health Serv Res Manag Epidemiol Date: 2017-11-02