Abstract 11505: Economic Effect of Third-Party Payor Pre-Authorization Policy for Nuclear Stress Perfusion Imaging
Background: To reduce inappropriate use of myocardial perfusion imaging (MPI), the largest health insurance provider in Western Pennsylvania implemented a Pre-Authorization(PA) policy for all MPI procedures in September 2010. Information regarding non-MPI testing was provided to physicians in the geographical coverage area, with an emphasis on stress echocardiography(SE). This study was designed to assess the economic effects of this policy on cardiology practices.
Methods: The number of MPI studies, SE studies and non-imaging exercise tests were computed for the 1st quarter 2010 (prior to PA mandate) and for the 1st quarter 2012 (after PA mandate). The ratio of each type of test was computed for each time period, as a % of total tests. Using Medicare data, total change in reimbursement as a direct result of the PA policy was computed per 1,000 patient studies. The actual cost of compliance with the policy was computed per 1,000 patients, including physician time, office staff time, and overhead costs.
Results: During the 1st QTR 2010, 82.1% (636 of 775 patients) underwent MPI, while 17.9% (139 of 775 patients) had a SE. During the 1st QTR 2012, 74.6% (676 of 906 patients) underwent MPI, while 25.4% (230 of 906 patients) had SE. The number of non-imaging stress was identical in both study periods. Using a Medicare reimbursement of $770 per MPI and $355 per SE, the total reimbursement for stress testing per 1,000 patients decreased from $695,300 to $666,250 resulting in a loss of $29,050 related to the change in the ratio of each type of study after the PA policy. Using a physician time cost of $19.70 for 6 min, an office staff cost of $0.50 /min for 45 min and overhead $8.00 per case, the cost of PA policy implementation was $50,000 per 1,000 patients. The total economic impact of the Pre-Authorization policy was $79,050 per 1,000 patients.
Conclusions: A payor Pre-Authorization policy for MPI resulted in a loss of $79,050 per 1,000 patients, using actual practice data before and after the policy. The policy resulted in a significant decrease in MPI (82.1% to 74.6%, p< 0.001) and a significant increase in SE (17.9% to 25.4%, p< 0.001). The economic loss results not only from a decrease in total reimbursement, but also from an increase in costs associated with policy compliance.
- © 2013 by American Heart Association, Inc.