CBO: Prior authorization for Medicare imaging does not produce savings

The latest Congressional Budget Office score of the economic effects of healthcare programs indicates that using prior authorization schemes in the Medicare program won't produce any savings.

"Research shows that relying on prior authorization programs, such as the use of for-profit radiology benefits managers (RBMs), for advanced imaging increases costs and red tape, placing a burden on physicians," Gail Rodriguez, executive director of the Medical Imaging and Technology Alliance (MITA), said in a statement. "These programs also create an artificial barrier for patients in need of care, and can lead to significant delays in treatment or inappropriate denials of coverage."

An analysis of Patient Advocate Foundation (PAF) patient data on imaging access between June 2007 and June 2011 published last month found that 81 percent of insurance denials for imaging procedures were due to prior authorization programs, with stated reasons such as "not medically necessary" or "necessary prior authorization needed to be obtained."

The analysis also found that slightly more than 90 percent of the image case denials that were reversed involved denials for imaging services that actually were covered within the patient's health plan.

"CBO has confirmed that implementation of a prior authorization program will not only produce zero cost savings, it will insert an artificial barrier between physicians and their patients," Tim Trysla, Executive Director of the Access to Medical Imaging Coalition, said in a statement. "Seniors rely on medical imaging for early detection and to guide their treatment on the road to survivorship. Instead of policies that harm patient access without yielding any cost savings to the federal budget, AMIC encourages Congress to advance policies that encourage the appropriate use of medical imaging."

To learn more:
- see the CBO score
- read the statement from MITA
- read about the Patient Advocate Foundation analysis
- see the AMIC statement