advertisement
Looking for something on the site? Search for it here! Also see Clark's Greatest Hits

Nov 17, 2008 -- Insurers using RBMs to deny coverage for radiological tests

Have you ever had an MRI, CAT scan or other radiological test? The use of such tests has surged by 50% in the last 5 years. They're potentially life-saving tests. But they're also over-prescribed by doctors who are afraid of being hit with a malpractice suit for not running the tests. This is also known as "defensive medicine."

To complicate matters, the big insurers are now using RBMs -- radiology benefits managers -- to assess whether they want to cover the procedures or not. A Wall Street Journal reporter found case after case where an insurer would pre-certify a radiological test and then, after the fact, turn around and deny payment based on the recommendation of their RBMs.

So what can you do? Before you proceed with any radiological test, get approval in writing -- even if pre-authorization isn't necessary. Don't settle for approval over the phone; you must get it in writing.

If you've already had a test done, and you're getting a referral to another doctor who is suggesting another test, take your films with you instead of undergoing a duplicate test.

Unfortunately, Clark won't be able to answer any questions submitted via commenting. If you have a question, please try posting it to our message boards.

Avg. rating: N/A

What others are saying

  • sad state of medicine
    I am amazed at how hospitals can get away with all of the abuses that they get away with. Republican radio has made socialized medicine seem so horrible, but we are getting to the point where only the rich get medical care. I am thinking about going to med school in a couple years so socialized medicine would probably hurt me personally, but I still think the country needs to do something different.
  • RBMs
    If we ever have socialized medicine in the USA it will be because of companies like these.
  • Radiology overuse
    I am retired now, but watched overuse of radiology grow exponentially. Radiologists often issue self serving reports with phrases like "borderline normal chest x ray. CT scan may be advisable given the borderline size of the heart." They also try to get a MRI out of every CT with this patter. Specialists don't fall for it as often as Family practice.
  • Lying liars lie
    Hospitals are liars, insurance companies are liars. I had an outpatient procedure in July where the hospital provided a written estimate of the cost and my insurance company approved it. Two months later, the hospital sends me a bill and wants $230 more (about 10%) claiming they had extra expenses for outside lab work. My insurance company is going to pay about 90% of the hospital's original bill even though they had approved the full amount earlier! They now claim the hospital's original charge was too high for that procedure. So between these two I'm looking at a 20% higher fee and that comes out of my pocket.

    This system is so screwed up!
  • Medical Test
    Ask your doctor why he needs the test done. My son works for a start up, so no insurance except a HSA with only about $800 in it. Doctor wants a cardiac MRI during a routine ck up (son had heart surg as child). We had to get procedure code numbers from Dr. so we could get prices from the Hospital. Radiologist fees to read the test are additional. Hospital says the cardiac tests would cost $10,000. The reason why Dr. needs the test -'I always order those test every 5 years.' Patient having no pain, no indication of a problem and Dr. had no idea those test cost that much. Outcome, no test done.
send to a friend  view as printer-friendly  RSS feeds
advertisement
advertisement
THIS WEEK'S POLL
advertisement