Self-referred imaging has grown rapidly, raising concerns about increased costs and compromised quality of care. A quality improvement program using imaging interpretation criteria was designed by a national payer to ensure that noninvasive diagnostic images are interpreted by appropriately trained physicians. The objective of this program evaluation was to compare self-referral rates before and after institution of the imaging interpretation criteria program.
The imaging interpretation criteria program allocated privileges to bill for advanced imaging interpretation according to physician specialty. Nonradiologist physicians could obtain exemptions by appeal. Some physicians were not restricted in their billing because of successful appeals of the restrictions or the timing of their contract renewals. Self-referral rates were compared between the period 12 months before and 25 months after the program was initiated using t tests. The preprogram and postprogram self-referral rate for computed tomography and magnetic resonance imaging in aggregate was calculated both for the physicians that came into contact with the program and nationally, and then was stratified based on physician appeal status and reimbursement restrictions.
The program was associated with significantly less frequent self-referrals by physicians whose appeals were denied (17.4%–8.2%; P = 0.0011) and by physicians notified of the program but not subject to it (24.8%–18.5%; P = 0.026). Self-referrals in the program states declined from 19.9% to 13.7% (P < 0.01).
A significant reduction in image interpretations billed by physicians working outside of the scope of their training occurred after the implementation of the imaging interpretation criteria program.
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
From *HealthHelp, LLC, Houston, Texas; †Humana Inc., Louisville, Kentucky; ‡Thomas Jefferson University, Philadelphia, Pennsylvania.
Correspondence: Adam C. Powell, PhD, 16945 Northchase Drive, Suite 1300 Houston, TX (e-mail: firstname.lastname@example.org).
Conflicts of Interest and Source of Funding: No external funding was provided for this study. A.C.P., E.M.K., A.K.G., and D.C.L. conducted this research as a part of their job responsibilities for HealthHelp. J.W.L. conducted this research as a part of his job responsibilities for Humana. HealthHelp and Humana were involved in the collection of data, its analysis and interpretation, and determining whether to publish the finished manuscript. A.C.P. additionally reports employment by Payer + Provider Syndicate and the reimbursement of travel expenses by the American College of Radiology. J.W.L. additionally reports Humana stock. E.M.K. was a HealthHelp employee at the time this manuscript was written and is currently a Humana employee with no additional disclosures. A.K.G. additionally reports HealthHelp stock. D.C.L. additionally reports board membership at Outpatient Imaging Affiliates.
Funding for the development of this manuscript was provided by HealthHelp and Humana, in the form of general compensation provided to the authors. The authors were compensated for participation in research activities as a part of their job responsibilities, rather than for this particular study.