Jones: Change authorization for medical procedures

Rep. Caleb Jones, R-California, has proposed two bills that seek to change how physicians receive authorization to perform certain radiology procedures, as well as to change the timeline to get authorization from insurance carriers.

The first bill allows physicians to use a computerized clinical decision support system as an alternative to authorization from radiology benefit managers for Medicaid patients.

A clinical decision support system can analyze data to help physicians make clinical decisions, such as whether someone needs a certain procedure.

Radiology benefit managers are individuals who provide prior authorization for imaging services.

“We spend $2.3 million a year for radiology benefit managers,” Jones told the House General Laws Committee on Tuesday. “I believe we can do it better and cheaper.”

He wants to give the state the option to choose what program to use for Medicaid.

“I agree that we need some kind of system in place to check and make sure we’re doing the right thing for citizens of Missouri,” he said. “I want us to have the option to look at this CDS (clinical decision support) system.

“But, this doesn’t require us to do one or the other.”

Elisabeth Quam, executive director of the CDI Quality Institute based in Minneapolis, said radiology benefit managers often act as gatekeepers and make it less likely for physicians to order unnecessary procedures.

“Clinical decision support is today’s next version of how to document the appropriateness of care,” she said.

“It really allows the trust factor to remain between a patient and physician without a third party being involved.”

Dr. Alan Henry with MedSolutions spoke in opposition to the legislation because he said less advice is taken from the clinical decision support system than from radiology benefit managers.

Jones also presented a bill to the committee that seeks to reduce the timeline from two working days to 24 hours for a health insurance company to make benefit determinations.

“But, serious and urgent conditions are exemption to proceed without authorization,” he said.

David Jackson with the CDI Quality Institute said the exemption would create a middle ground for physicians and insurance companies. His company is in favor of the legislation.

Those in opposition are concerned with the bill’s definition of emergent and serious conditions.

“Who makes that decision?” asked David Smith, a lobbyist with Anthem Blue Cross Blue Shield of Missouri. “When do we think that the doctors are always right in that determination?

“Prior authorization is used to protect the consumer.”

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