By now, many of our members have experienced, read, or at least heard about three dreaded requirements being considered and/or imposed by private insurance carriers before we perform a cardiac ultrasound study: preauthorization, precertification or pre-notification of echo studies. In recent years, ASE’s efforts to oppose these private payer initiatives have become such a large part of the Advocacy Committee’s work that a special subcommittee, chaired by Drs. David Wiener and Raymond Stainback, was formed last year. Together with other volunteers, including Drs. Linda Gillam, Thomas Ryan, Michael Picard, and John Dent, ASE Coding Consultant Judy Rosenbloom, and others, have been extremely busy analyzing and crafting responses to Local Carrier Directives (LCDs), meeting with payers, and collaborating with the ACC’s private payer team to strongly advocate for alternatives to these labor intensive programs and, at a minimum, ensure that these initiatives are crafted with consideration for our patients, practices and appropriateness criteria. ASE has also contracted with Preferred Health Strategies (PHS), a consulting firm which specializes in working with private payers, to help fight this battle and work towards obtaining the best outcome for our members.
What, Exactly, is the Issue?
Since the use of echocardiography has increased substantially in recent years, with an estimated 70% of the studies ordered by non-cardiologists, payers have become concerned that some of the tests may be unnecessary or duplicative. Concerns about excessive imaging costs have led to the introduction of a variety of utilization management programs and the use of outside vendors called Radiology Benefit Managers (RBMs) to assist the private insurance carriers with the development, implementation, and monitoring of study ordering. The ASE/ACCF Appropriateness Criteria have been incorporated into many of the utilization management programs; however, these programs are generally based on the need to personally reply to a series of questions and subsequently the vendor deciding on whether to authorize the respective test. This system is applied broadly to all providers and to all tests that fall within specific imaging codes.
Prior authorization programs in echocardiography will represent a significant administrative cost and burden for ASE member providers, and will frequently become the source of significant disruption for the delivery of effective and timely care to our patients. Primary among our concerns are:
increased administrative costs for the practice to manage the process
lengthy wait times and delays in approvals
frequent requests for additional information of questionable clinical value
subsequent payment denials that are generally appealed and often overturned
disruptions in the clinical service for our patients
Recent studies have questioned the long-term effectiveness of prior authorization programs, suggesting that while savings accrue in the first year, second year savings are mixed. But more importantly for ASE members, the programs, as currently envisioned, are excessively burdensome to practices and will occur at the expense of the large majority of providers and patients who have legitimate clinical need for the tests.