March 11, 2016

Hawaiian Radiologists Battle Against Prior Authorization

The Hawaii Radiological Society (HRS) has been joined by the American College of Radiology (ACR), physicians and patients to support legislation that would prohibit the state’s health insurers from requiring prior authorization that causes undue delays in medical treatment.

House Bill 2740 was introduced in the Hawaii Legislature after the Hawaii Service Association (HMSA), an independent licensee of Blue Cross Blue Shield of Hawaii, implemented mandatory preauthorization in December 2015 for physicians who seek advanced medical imaging procedures, such as MRI or CT. The preauthorization requirement applies to Blue Cross Blue Shield coverage for more than half of the 1.4 million residents of the Hawaiian Islands. HMSA contracted National Imaging Associates, a radiology benefits management company in Arizona, to administer the program.

At a March 4 hearing of the State Judiciary Committee, lawmakers learned from testimony by physicians and patients that the pre-approval requirements are putting patients at risk. Physicians complained about waiting for weeks for preauthorization approvals. They said the resulting treatment delays are especially dangerous in Hawaii, considering a vast majority of its physician practices provide services from small independent offices that, unlike larger hospital systems, do not have dedicated administrative staff support to invest work hours into communications with a mainland-based company.

HMSA was firm in asserting that its prior authorization policy was put in place to prevent unnecessary testing.

A number of physician specialties — with radiology, neurology and surgery among them — testified about the additional stress the new requirements have imposed on their practices. Guidelines used by third-party benefit management companies are often proprietary and do not use recognized national peer-reviewed standards to assess the appropriateness of physician orders. Moreover, they said the lack of transparency for financial arrangements between state insurers and third-party reviewers raises questions about a possible connection between percentage of denial rates and cost controls.

In a letter of support , HRS advised insurance carriers as follows that there is an alternative solution to the use of preauthorization:

Understanding the daily obstacles and financial stresses faced by Hawaii physicians, HRS and HMA advocate the immediate use of an evidence-based Clinical Decision Support Tool, whereby imaging requests are vetted against the American College of Radiology (ACR) Appropriateness Criteria at the point of care. Providers will receivereal-time feedback on the clinical utility of a request, and, if necessary, be guided to either a more appropriate exam or given consideration for direct consultation with a local Radiologist. This will be a useful instrument to complement the expertise of Hawaii's primary providers and imaging specialists. There are 25 years of research and development of this tool, and it is now available FREE through a web portal to all Hawaii physicians. Additionally, the Choosing Wisely guidelines pertaining to imaging are generally aligned with the ACR Appropriateness Criteria.

In an open letter, ACR Chief Executive Officer William T. Thorwarth, Jr., MD FACR, affirmed the College’s support of ACR Appropriateness Criteria® through Computer Decision Support (CDS) as a superior to prior authorization administered by benefit management firms for facilitating value-based care and controlling imaging utilization. He stressed this tool easily fulfills the requirements of the impending mandate by the Centers for Medicare & Medicaid Services that will require physicians to consult government- approved, evidence-based appropriate-use criteria when they order advanced diagnostic imaging exams (CT, MRI, nuclear medicine and PET) for Medicare patients.

More expressions of support and opposition to H.B. 2740 are available for online review in the following files: File 1. File2.