NASHVILLE, Tenn.. – May 29, 2007 – Amid sobering reports that almost half a billion radiology procedures will be performed annually by 2008, there is industry-wide concern regarding the collective impact of waste, fraud and abuse upon the overall cost of care as well as patient exposure to radiation. MedSolutions, providing radiology management services for nearly 25 million individuals nationwide, points out that high tech, high price imaging costs are growing faster than pharmacy drug expenditures, with low-tech imaging representing one of the most fertile areas for abuse.

"Waste is expensive, with unnecessary imaging estimated to cost the country billions, possibly even as high as $10 billion annually," states Gregg P. Allen, M.D., executive vice president and Chief Medical Officer of MedSolutions. "When these procedures are warranted by patient condition, they are among the best diagnostic tools available. But procedures that are simply ordered as a result of patient demand, physician uncertainty, or lack of information, the result is the performance of unwarranted studies, with attendant unnecessary costs, and in some cases risk to the patients involved."

Dr. Allen cites additional culprits that contribute to waste including defensive medicine, use of imaging studies in place of the physical exam, multiple and repeat screening studies, lack of knowledge regarding the appropriate imaging study, increasing tendencies towards aggressive surveillance and treatment of incurable diseases, and direct-to-consumer marketing.

"Fraud and abuse, on the other hand, encompass a wide range of improper billing practices that include misrepresenting or overcharging with respect to services delivered," he explains. "Both generate unnecessary costs to the insurer, but fraud generally involves a willful act, whereas abuse typically involves actions which are inconsistent with acceptable business and medical practices."

Dr. Allen says that self-referral leads to abuse since there is a clear incentive for physicians to perform imaging studies when the practice will financially benefit from the study being performed. However, instances of in-office imaging continue to grow as physician groups look to expand sources of practice revenue. In fact, studies indicate that physicians self-refer patients to owned equipment as much as four times more often when compared to practices without in-office equipment ownership.

"Fraud is unacceptable," he advises, citing the rapid increase of imaging equipment into the outpatient setting, the lack of equipment standardization, and the increase in in-office imaging raising additional opportunities for fraud. "The reading of imaging studies by unqualified professionals is particularly troublesome, as are instances where a physician will submit a bill for studies and contrast material - and simply neglect to provide the service."

He advises that patients also pay the price, with unnecessary exposure to radiation posing serious quality implications for patient care.

"The National Cancer Institute estimate that the use of CT in both adults and children has increased 7-fold in the past 10 years with CT scans estimated to contribute 64 percent of the effective radiation dose from all medical x-ray examinations to the population," says Dr. Allen.

With the help of radiology management firms, many health insurers, including Medicaid, are instituting utilization management programs to address these examples of fraud, waste and abuse. Managed care decision makers recognize that radiology spending now accounts for about 10 percent of every healthcare dollar and must be controlled.

"Payers need viable strategies to minimize physician self-referrals, impose credentialing criteria, initiate independent activities to assess providers' competency to perform diagnostic imaging services, and institute pre-authorization programs for non-emergency outpatient CT, MRI and certain other diagnostic imaging studies," concludes Dr. Allen.

He says that the goal is to help physicians find the procedure that will give them the best diagnostic information for each patient, supporting them with the radiology expertise they need and the guidance that will help patients avoid unnecessary exposure.

"A first priority is to serve members, ensuring that they receive the best possible imaging exam for their condition, as quickly and efficiently as possible."

 About MedSolutions

MedSolutions specializes in managing radiology services for national and regional health plans as well as federal and state government agencies, maintaining management contracts for nearly 25 million individuals nationwide. The company leverages sophisticated analytics, personalized call center operations and extensive radiology care management experience to provide the most innovative, cost-effective radiology management solutions in the industry. MedSolutions is now recognized for call center operation customer satisfaction excellence under the esteemed J.D. Power and Associates Certified Call Center Program (SM). MedSolutions is the only radiology management company to be certified under the program.