The health care system seems to be keeping tracking of every cookie a consumer eats these days and every blood pressure check the consumer misses.
Primary care physicians feel as if they’re being put through a cost-saving meatgrinder.
One group that might be escaping some of the pressure is radiologists, and especially radiologists who conduct “advanced imaging” procedures such as MRIs and PET scans.
America’s Health Insurance Plans, Washington, has estimated that radiology accounts for about $100 billion in annual U.S. health care expenditures, and that that amount could double in the next 4 years.
Consultants at Milliman Inc., Seattle, have suggested in a report prepared for a unit of Magellan Health Services Inc., Avon, Conn. (Nasdaq:MGLN), that successful radiology benefits management (RBM) programs could save more than $13 billion by 2020 for the traditional Medicare alone.
One example of challenges with radiology claims costs is the famous problem of radiologist balance billing.
At the typical health plan, the patient has a very easy time finding an in-network hospital and a reasonably easy time finding in-network primary care doctors and in-network specialists. But, in many cases, a patient who enters an in-network hospital with the intention of seeing only in-network providers has a terrible time seeing in-network radiologists.
The radiologists often shun networks. Instead of accepting a plan’s estimate of the “reasonable and customary” rate for radiology services and taking the plan’s payment as payment in full, a radiologist often stuns the patient — who had worked hard to get only in-network care — by billing the patient for the balance.
The RBM companies are expecting to do more business in the next few years as rising costs, a soft economy and pressures related to the Patient Protection and Affordable Care Act of 2010 (PPACA) give public payers, private insurers and employers that sponsors self-insured plans a stronger incentive to squeeze out every dime of costs.
Kevin Howat, executive vice president of business development at Care to Care L.L.C., New York, says health insurance agents and brokers should be paying close attention to RBM trends.