Overutilization of healthcare resources is a major issue that costs hundreds of billions of dollars each year. To help circumvent this, the American Board of Internal Medicine (ABIM), has recommended a reduction in the use of tests and procedures that provide no benefit to patient care. They generated a list of 5 recommendations regarding potentially unnecessary medical tests and procedures.
Recommendations
One recommendation suggests limiting 20% to 50% of high-tech radiologic imaging that is considered to not be valuable to a patient suffering from non-specific, short-term lower back pain. Diagnostic imaging is often not of value in this situation and can be wasteful. Oftentimes, insignificant abnormalities are found, which drives even more follow-up imaging. Additionally, exposure over time to radiation can put patients at-risk and utilizing resources unnecessarily can impact the access to these services for patients who legitimately need them.
Identifying Inappropriate Patterns
It’s important to identify notable inappropriate use patterns and then pin-down exactly why they’re occurring. When an inappropriate pattern is noted, the payer might need to be able to adapt internally through the development of a policy that outlines appropriate medical requirements for a specific service. When your policies are clear and concise, an initial denial and request for records or a letter of medical necessity could be an appropriate response.
Solutions
Sharecare Payment Integrity (formerly WhiteHatAI) constantly updates our FWA software, giving you cutting-edge solutions to save you money. Through our solutions, we can assist you in identifying patterns that can impact your payer environment.
