Clamping a Lid on Scans

Faced with soaring costs for imaging scans like MRIs, health insurance companies are turning to radiology benefits managers, or RBMs, to try to get a handle on these expenses. The idea is to confirm that a scan is medically necessary, a decision the RBMs say is based on scientific evidence and guidelines from medical groups. Many doctors, on the other hand, claim that the approval procedure can result in delays or outright rejections that can put a patient at risk. An estimated 90 million consumers, about half of all Americans who have private health insurance, are covered by insurers that have hired RBMs.

The move to RBMs is primarily the result of an explosion in the number of scans. The combined total of CT and MRI scans hit 96.2 million in 2007, up 43% from 2002. The number of PET scans in 2005 was about 1.1 million, more than triple the number in 2001. Insurers claim that there is evidence that some of these scans aren’t medically necessary, with many being done primarily to protect doctors from potential malpractice liability.

Although RBMs have been around for nearly 20 years, their use has grown with the recent upsurge in both utilization and costs. The cost of a scan can vary by the mode and by what’s being scanned. Medicare pays about $230 for a CT scan of the head, and just under $1,000 for an MRI of the neck and spine. PET scans can cost as much as $2,000 or more.