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Dr. Tomaino's Blog

Preapproval for MRI studies

January 2nd, 2009
Happy New Year to all. Here's looking to a wonderful,healthy, and prosperous New year. Although our spirit of hopefulness and enthusiastic commitment to newly identified "New Year's resolutions" contributes to a healthy optimism for 2009, there will undoubtedly be hurdles to contend with.

One such hurdle remains, for now,outside my circle of influence--and relates to Excellus's requirement for those insured by it's "Blue" products, that MRI scans be "preapproved". This preapproval process--administered by CareCore-- is aimed at stopping unnecessary utilization of expensive studies, and assumes, at face value, that all requests for MRI's may be frivolous.

In fact, the vast majority of MRI's get approved, but every physician--even Specialists-- are forced to "prove" the necessity of the study. This evolved, I imagine, because many studies were ordered before more fundamental diagnostic and treatment alternatives were tried. And, we all need to do our part to reign in the costs of care.

But, why not spend the resources to identify, audit and reform the outliers---those providers who may unnecessarily over-order MRI studies? Why penalize doctors "in the know" as well as their patients?

Indeed, as a shoulder, hand and elbow specialist, when I order an MRI it's because I need to either decide to perform a surgical procedure or prepare for an upcoming surgery based on the additional information provided by the MRI. My training and expertise are the basis for requestiong the study. Sometimes the study is ordered to evaluate a tumor or question thereof. But, as it currently stands, our staff need to spend time navigating these hurdles rather than speding time with more critical matters.

There is a better way, but we all need to participate in finding it. At the very least, this may be a reason to call your customer service representative, or to evaluate your options for Health Insurance next year. "Managed care" should not be equivalent to "Rationed care."

For the time-being, thank you for your patience if we are forced to delay your MRI in order to comply with Excellus' rule that preapproval is required.


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