Privileging limits access to imaging, cuts insurers' costs

With the growing use of physician privileging, a license to practice medicine no longer functions as a free pass for practitioners to perform whatever diagnostic imaging they choose in their clinical practice. Private insurers are learning that privileging-policies that permit payments only to physicians who possess specific educational credentials-can combat inappropriate utilization and prevent shoddy quality.

As required by some privileging programs, more facilities are applying for accreditation to demonstrate competence. Registered technologists are performing more imaging, and radiologists are contracted in more instances for interpretation or overreading. Physicians appear less likely to bill insurers for imaging services they are marginally qualified to perform. Some plans are saving money by eliminating what they consider wasteful imaging volume.

Highmark Blue Cross Blue Shield, Oxford Health Plans in New England, Health Insurance Plan of Greater New York, and Group Health Incorporated and HealthNet in New York and New Jersey were among the first private insurers to gain experience with physician privileging. Tufts Health Plan in Massachusetts and Humana Kentucky inaugurated programs in September.

By most accounts, Highmark has gone further than other insurers to enforce standards that limit the ability of nonradiologists to perform high-tech imaging. The program, implemented in August 2004, will pay for outpatient MR and CT only when it is performed by facilities offering at least five imaging modalities. Services must be open for business at least 40 hours a week and staffed with a radiologist who holds advanced life support certification and a licensed technologist. The policies, which initially affected beneficiaries in western Pennsylvania, were extended to central Pennsylvania last fall. Highmark contracted utilization management consultant National Imaging Associates to help set up the program.

Echocardiography, MRI, nuclear cardiology, ob/gyn ultrasound, peripheral ultrasound, and PET services must be accredited or be in the process of receiving accreditation from the American College of Radiology, the Intersocietal Accreditation Committee, or another accrediting agency. With few exceptions, a hospital must be involved in the ownership of PET equipment used by Highmark members.

Some procedures are limited to specific physicians. Fluoroscopy must be performed by a radiologist; breast ultrasound may be performed by a radiologist or a surgeon certified by the American Society of Breast Surgeons. Obstetrical ultrasound is reserved for ob/gyns and radiologists. Nuclear cardiology may be performed by radiologists, nuclear medicine physicians, and physicians certified by the Certification Board of Nuclear Cardiology. Peripheral vascular ultrasound is the province of radiologists, vascular surgeons, cardiologists, and neurologists. Bone densitometry must be provided by a radiologist, endocrinologist, rheumatologist, ob/gyn, orthopedic surgeon, internist, family practitioner, or primary-care physician. Plain-film imaging must be acquired by a certified technologist and interpretation performed by a radiologist.

Equipment performance is defined in some instances. MR scanners must be capable of also performing MR angiography, a requirement that would deny reimbursement for imaging done on dedicated extremity scanners. Ultrasound scanners used in echocardiography and peripheral vasculature applications must perform color-flow Doppler procedures.

As of Oct. 1, 89% of about 1000 freestanding and in-office imaging providers were approved to bill Highmark under terms of the new criteria. As a result of Highmark BC/BS privileging rules, 11% of practices equipped for diagnostic imaging stopped billing Highmark for radiological services. Of those that stopped billing:

60% were only involved with plain-film imaging;

25% were performing imaging considered outside the scope of their physicians' competence; and

6% were single-modality providers, all open MRI centers equipped with 0.3T or lesser field strength magnets.

Various odd combinations appeared in the "outside the scope" category, the strangest being an obstetrician who was performing nuclear cardiology, said Dr. Carey Vinson, Highmark's vice president of quality and medical performance management.

MR and CT services met the minimum five-modality requirement by combining facilities or adding modalities, such as fluoroscopy and mammography. Ultrasound was particularly popular because it qualified as several modalities under the program specifications.

It is not clear whether the multimodality requirement will help stall the proliferation of single-modality MRI centers. Open MRI services had been a major source of complaints about poor quality, and those centers recruited technologists who could have been more wisely deployed to other types of imaging services, Vinson said.

The push toward accreditation may have been the great achievement of privileging at Highmark. More than 25% of the services, or about 325 facilities, applied for accreditation after it became a requirement.

In contrast to most insurers, Highmark implemented privileging before instituting preauthorization to certify the appropriateness of prescribed high-tech imaging. That initiative will begin next spring following a year-long notification phase to familiarize referring physicians with the reporting process.

Some question whether the Highmark approach can be applied elsewhere. Its 70% market penetration in Central Pennsylvania gives it enough leverage to force providers to comply, according to Jessica Riley, director of marketing for MedSolutions, an imaging utilization management company in Franklin, TN.

Other physicians might not be so acquiescent in giving up a source of revenue, Riley said. She also questions whether multimodality requirements offer a defense against self-referral. Self-referral practices are so lucrative that providers are willing to buy and then shelve several modalities just to retain the right to bill for their existing in-office imaging services.

CARECORE'S APPROACH

CareCore's privileging criteria have been adopted by Group Health Incorporated, Health Insurance of Greater New York, HealthNet in New York and New Jersey, and Oxford Health Plans in Massachusetts.

Although terms vary among the insurers, CareCore emphasizes ways to restrict in-office self-referral. Qualified cardiologists can be privileged to interpret cardiac MRI in hospitals or from an independent freestanding imaging service, but the programs will not grant them privileges for reading studies performed on in-office scanners. Their groups are barred from charging the insurer for technical or global fees covering self-referred services.

"Our position would be to separate the professional side and who reads and does not read studies from the technical side of the cost of having all those office-based units proliferating around the market," said Donald Ryan, CEO of CareCore National. The programs have thus far reduced utilization rates by 3% to 5%. Lower utilization has translated into cost savings ranging from 72¢ to $1.39 per member per month (see table).

"Privileging is the most powerful tool available to limit inappropriate self-referred volume," he said.

PRIVILEGING IN KENTUCKY

HealthHelp implemented its Radscope privileging program in September. Humana Kentucky accepted the first installation, applicable to about 600,000 beneficiaries.

Radscope will be guided by 43 policies based on CPT codes to define the scope of billable imaging procedures, said Cherrill Farnsworth, CEO of HealthHelp. Reimbursement will be limited to specific procedures the insurer deems the practitioner qualified to perform. Payment will be denied for procedures outside the designated categories.

HealthHelp's Dr. David Levin wrote the privileging criteria based on traditional practice patterns and residency and fellowship training requirements for various physician subspecialties. Orthopedic surgeons gained the right to read plain films because of their training in skeletal x-ray interpretation and the longstanding tradition of plain-film imaging in orthopedic offices.

Cardiac CT and MR were reserved for radiologists, however, despite recent efforts by the American College of Cardiology to define competency criteria for the modalities. Levin admits that the ACC and ACR criteria for cardiac CT are similar, but radiologists spend years learning to perform and interpret CT and MR, while cardiologists are required to have only a general familiarity with how the modalities operate.

"You can be sure that a radiologist who has board certification really knows the workings of a CT, MR, or PET scanner as well as how to interpret the images," he said.

Farnsworth said she is confident that image quality will improve as equipment owners are forced to concentrate on performing the imaging applications they know best and that utilization will drop as the program eliminates extraneous procedures. A preliminary analysis found that imaging costs associated with physicians who practice outside their core competency are greater than expected, she said.

Privileging appeals to healthcare insurers because it addresses one of their fastest growing costs. The Blue Cross Blue Shield Association estimates that about 400 million medical imaging exams will be performed in the U.S. this year. That figure is expected to increase by another 50 million procedures in 2008. A large proportion of that growth stems from PET, multislice CT, and MRI, the most expensive imaging modalities for insurers. Setting privileging standards to regulate those modalities can be justified on the basis that many physicians do not receive the extensive training needed to assure their competent use.

Although medical imaging covered by Highmark Blue Cross Blue Shield of Pennsylvania is growing 10% per year, the use of those three advanced modalities is expanding 20% per year, Vinson said. Insurers typically pay $2000 for PET and $800 and $700 for the global costs of MRI and CT, respectively. Typical payment for routine x-rays is about $100.

Physicians equipped to refer patients for these services in their offices are three to five times more likely to use medical imaging than physicians who are not in a position to self-refer, according to CareCore's Ryan.

"Self-referral is a big problem; it has been clearly demonstrated," he said.

The American College of Radiology, which opposes self-referral, supports privileging to control it. The Highmark approach could serve as a model for Medicare to establish quality standards for advanced medical imaging, said Dr. James Borgstede, chair of the ACR board of chancellors.

The American College of Cardiology opposes privileging just as strongly as the ACR supports it. In a statement issued to Congress in February, the ACC argued against mandatory accreditation, privileging, and other actions that it said could result in arbitrarily denying patients access to necessary diagnostic imaging services.

Privileging has nothing to do with healthcare quality, according ACC president-elect Dr. Steven E. Nissen.

"It is all about cost-containment," he said.

Mr. Brice is senior editor of Diagnostic Imaging.