By Lief Goodson, COO and SVP Analytics, Xerox Workers’ Compensation Solutions
In last week’s issue of Leaders Speak, we discussed the advantages of approaching medical cost containment as an ecosystem – bringing the parts together for greater agility, efficiency and security.
Another argument for all-in-one, “end-to-end” system design is the ready availability of data for analysis. Large amounts of warehoused data can provide fertile ground for the sophisticated analyses of medical bill review and claims data and the deployment of decision-support tools.
Recently, the Xerox analytics team explored our book-of-business data to evaluate treatments and outcomes for work-related, low-back injuries. While our primary goal was to characterize the treatments that worked best, we also wanted to find out if there were clear indicators for when a low-back claim “goes bad” in terms of cost and duration.
Since historic medical and industry research has shown a strong correlation between MRIs and prolonged medical treatment and extended disability, we wanted to answer relevant questions about the use of MRI studies in the treatment of work-related injuries. We examined five years’ worth of retrospective bill review data (2010-2014), and here’s what our analysis of the data showed:
Utilization by Body Area
MRIs were performed on about one-third of claims for shoulder and elbow injuries. Specific to back injuries, the use of MRIs for lumbar injuries was over 25 percent in 2010, but declined to just over 20 percent in 2014. In comparison, only about 10 percent of cervical injuries received MRIs as did 3 percent of thoracic injuries. MRIs were performed on 22 percent of hip and knee injuries.
While MRI procedures are very consistent throughout the U.S., the cost and utilization of MRIs varies widely by state. While Florida and California have two of the highest MRI utilization rates in the country, they also have some of the lowest MRI costs. For example, in 2014, MRIs performed in both states averaged under $500 per scan. In states like Wisconsin and Alaska, MRIs averaged between $1,000 and $2,000 apiece. Also, for the same injury type, workers’ compensation patients in Florida were almost twice as likely to have an MRI performed, with 1 in 4 workers’ comp patients receiving an MRI in 2014.
Most MRIs were billed with some type of CPT code modifier, which in most instances did not affect reimbursement. MRIs performed in a hospital or ambulatory surgical center were more likely to result in multiple invoices (one for conducting the test and one for reading or interpreting the result) and at higher rates (using severity modifiers). MRIs billed through a radiology network, on the other hand, typically had one invoice and did not include code modifiers impacting reimbursement.
The majority of MRIs were performed after the minimum time frames recommended in evidence-based treatment guidelines. However, the timespan between date of injury and an initial MRI declined over the 5-year period. MRIs were performed much sooner on extremity and joint injuries. Time frames from date of injury to the first MRI were about twice as long for back injuries compared to injuries of the upper and lower extremities.
MRIs and Surgeries
Over one-third of the claims with MRIs had surgery. Over 40 percent of joint injuries (upper and lower extremities) with an MRI had surgery. For back injuries with an MRI and surgery, the surgery was just over 100 days after the MRI. The quickest interlude between an MRI and subsequent surgery was 76 days, which occurred for joint injuries. About 10 percent of claims involving surgical intervention had MRIs performed after the surgery (on average 140 days after the surgery).
Almost 15 percent of claims receiving an MRI had a second MRI on the same body area. Typically, the second MRI was performed about 6½ months after the first MRI.
Although the utilization of radiology networks declined slightly over the 5-year period, radiology networks
significantly reduced the cost of MRIs and virtually eliminated multiple bills for a given MRI. There were also significant cost variations between radiology networks. In general, radiology networks provided discounts on state-mandated fee schedules of 30 percent to 35 percent.
MRIs Impact on Claim Cost and Duration
For diagnoses that almost always have an MRI performed (e.g., complete rupture of rotator cuff), the differences in claim costs and duration were nominal between claims with an MRI and those without an MRI. That notwithstanding, for most diagnoses, the claims with an MRI were more expensive and of longer duration than claims with the same diagnosis without an MRI. For lumbar strain/sprain claims, those with an MRI cost twice as much and lasted almost twice as long as those without an MRI.
Utilization Review of MRIs
Because MRI procedures are relatively inexpensive in most jurisdictions, they are often used as diagnostic tools to determine injury causality and relatedness. Unfortunately, most MRIs are not submitted prospectively (before the service is performed) for formal utilization review. Nonetheless, the number of MRIs requests that were “not certified” (i.e., denied) increased significantly over the past five years, especially in California. On the whole, MRI requests escalated to physician-level review were often denied during the utilization review process.
Some Key Takeaways
As expected, our analysis validated some things we already knew. It also led us to some key insights that can help our industry better understand and manage medical spend. Here are a few you can apply in your program right away:
- Radiology networks with client-specific selections based on price, quality and coverage can effectively contain MRI costs. Using claim and medical management staff to direct injured workers into these specialty networks helps to maximize the effectiveness of these networks.
- Employing evidence-based criteria to determine when an MRI is medically reasonable and appropriate eliminates variations in the application of MRIs based on state and claim demographics.
- MRI requests made before four to six weeks of conservative management or after 12 weeks without significant clinical deterioration or progressive neurological deficit should be carefully scrutinized for medical necessity.
- MRIs should be used to confirm diagnoses only in instances where the provider can articulate how the outcome of the test will guide treatment decisions.
- MRIs can show degenerative findings and pathology, which are not responsible for a patient’s symptoms and can lead to unnecessary intervention, including surgery.
- Repeat MRIs are rarely necessary unless there are significant changes in patient symptoms or clinical presentation suggesting a significant underlying anatomical or pathological change.
Copies of “Magnetic Resonance Imaging and the Injured Worker: A Retrospective Analysis of Cost, Utilization and Impact on Medical Outcomes in Workers’ Compensation” are available for viewing and download by contacting us at email@example.com.
About Lief G. Goodson
Lief G. Goodson is chief operating officer of Bunch CareSolutions, A Xerox Company, and senior vice president of analytics for workers’ compensation solutions at Xerox. His key areas of focus are analytics and technology, particularly the development of data systems, reporting capabilities and predictive modeling applications. He is currently responsible for strategic planning, innovation and quality assurance in all service areas.
Xerox is helping change the way the world works. By applying our expertise in imaging, business process, analytics, automation and user-centric insights, we engineer the flow of work to provide greater productivity, efficiency and personalization.