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MA health insurer alters procedures for imaging

Compliance Monitor, March 3, 2004

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Harvard Pilgrim Health Care, one of Massachusetts' largest health insurers, said physicians are ordering too many imaging tests, including MRIs and CT scans. As a result, it's returning to a traditional style of managed care to control these soaring costs, reported The Boston Globe on February 27.

Radiology costs at Harvard Pilgrim are skyrocketing, the Globe story stated. Harvard Pilgrim patients had 130,362 advanced imaging tests last year, costing the plan $73 million - a 62 percent increase in two years.

In many cases, it's a question of medical necessity. Harvard Pilgrim executives said some tests, particularly those for lower back pain and headaches, which are advertised heavily, may not be needed. The tests not only increase costs, but expose patients to unnecessary radiation and delay appropriate treatment for ailments that can be diagnosed without imaging, executives said in the Globe story.

Beginning April 15, Harvard Pilgrim will require physicians to approve all non-emergency advanced imaging tests with National Imaging Associates Inc. to evaluate whether the tests meet "nationally-recognized, evidence-based guidelines," the Globe reported.

If a physician schedules a test without calling the New Jersey-based radiology management company, Harvard Pilgrim will not pay and the patient or physician will end up with the bill. Until now, physicians ordered imaging tests themselves.

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