New Ways to Ensure Appropriate Use

Studies show that of the $100 billion spent on medical imaging each year in the US, an estimated $30 billion (20% - 40%) is deemed unnecessary. Health Plans carry the cost of unnecessary tests in a fee-for-service (FFS) environment, and hospitals carry the cost for capitated contracts (DRGs). Although numerous statistics point to a significant imaging utilization problem, few solutions optimize clinical quality and appropriateness, as well as manage risk (cost).

The current Health Plan approach relies on Radiology Benefits Management (RBMs) programs. RBMs attempt to decrease unnecessary imaging by requiring lengthy administrative prior notification or pre-authorization. RBMs processes create administrative hurdles that result in reduced utilization or claim denials. Imaging providers, referring physicians, and patients bear the burden of these blunt utilization management tools.

Transforming Payor Environments

Traditional fee-for-service environments are moving to managed care environments, such as the creation of Accountable Care Organizations (ACOs), and the establishment of risk sharing arrangements.

The Medicalis Utilization Solution provides a constructive means for Providers and Payors to collaborate and manage financial risk by controlling unnecessary imaging procedures, without affecting high quality, high-value care to patients and members.

Point-of-Order Clinical Decision Support

An ideal imaging utilization solution must benefit patient safety, clinical quality, and physician productivity, while contributing to better patient outcomes. Clinically appropriate high-tech diagnostic imaging is critical for patients.

Key Benefits of the Utilization Solution

• Patients receive better, and timely, care based on quality imaging practices without the risk of administrative denials.
• Physicians are no longer required to pre-authorize orders through a phone call center. Physicians are presented with evidence-based and clinical best practices guidelines and can be connected to local imaging experts who can most effectively aid in patient care though the use of Peer-to-Peer consultations.
• Imaging Providers are engaged in a quality-based utilization management program, with necessary transparency and accountability measures to align their business success with appropriate utilization. Health Plans can be assured that an accountable and transparent Utilization Management program is in place. Payors receive similar benefit to other utilization programs without the physician backlash and with less administrative cost.