The Medicalis Insight
Diagnostic Decision Support News
Volume 1
Issue 1
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Hello and welcome to The Medicalis Insight, a newsletter on diagnostic decision support and news from Medicalis Corporation. 

 

Over the past five years, Medicalis customers and staff have developed a wealth of experience in deploying radiology decision support to the point-of-care.  The Medicalis Insight is an opportunity to share that knowledge and recognize those who have been instrumental in the development and use of decision support in radiology.

 

We hope you enjoy the read and consider sharing your own insights in future editions.

 
In This Issue
Medicalis News
The Paradox of Preauthorization
 
Medicalis News
 
New Pre-Authorization Tools
Medicalis has launched upgraded Radiology Benefits Management capabilities that manage multiple pre-authorization programs and can facilitate or eliminate the need for phone-based authorizations.
 
CDI Signs as Luminary Imaging Center Network
Medicalis and CDI have signed an agreement that provides clinical decision support solutions to the CDI network of 39 diagnostic imaging centers in eight states.  Integration of Medicalis' solutions at point of service will enhance efficient and effective communications with referring clinicians, especially for those whose patients' specific insurance plans require pre-notification for advanced imaging procedures.
 
Visit us at SIIM 2007
Pre-authorization management tools and radiology decision support solutions will be highlighted.  Come visit us in Booth #1111.  June 7-10 Providence, RI.
 
The Paradox of Preauthorization
 
For many in radiology, pre-authorization programs are or will soon be a reality. A typical pre-authorization program today is directed at advanced imaging tests such as CT and MR, and generally requires physician offices to contact a third-party call center to review exam particulars and obtain an authorization. Staff at the call center may use a standard series of questions to determine exam necessity and provide authorizations as appropriate.

However, for physician offices that are affiliated with multiple managed care providers (Payers), the complexities of different program criteria for each Payer make it difficult to keep up with requirements and obtain the right authorizations. Even when authorizations are obtained, scheduling or exam changes may make re-authorization necessary, adding more complexity to the authorization process.

Once obtained, the authorization number is provided to radiology along with the order. Unfortunately, in the event that the authorization number is not valid, radiology reimbursement claims can be denied. The paradox of pre-authorization is that physicians are responsible for obtaining pre-authorization numbers but radiology is responsible for ensuring they are correct.

Pre-authorization Management Solutions

IT-based preauthorization management solutions can be used to facilitate pre-authorizations and give radiology greater confidence that claims will not be denied. Pre-authorization capabilities are a natural extension for radiology order entry solutions since identical order information must be captured.

The order information obtained (patient, insurance, exam, indications and schedule) can be cross-referenced against pre-authorization program criteria and flagged if pre-authorization applies. Procedural and contact information can then be provided on screen to help users follow the right authorization process.

In certain states, if Payers have EDI (Electronic Data Interchange) capabilities, pre-authorization requests can be automatically placed on behalf of the physician office. EDI, used as part of HIPAA administrative simplification requirements, also has a standard protocol (ANSI 278) for requesting authorizations. Integration of an order entry system with managed care EDI systems will eliminate administrative effort and ensure validity of any authorization requests.

Clinical Decision Support

If the goal of pre-authorization programs is to ensure exam appropriateness and reduce unnecessary tests, then they share the same goals as clinical decision support (CDS) solutions. The solution approaches however, differ greatly. CDS solutions strive to provide relevant knowledge at the time of decision-making, guiding the ordering process up front. Pre-authorization programs check on orders after they are placed and create a sense of oversight, not cooperation.

Progressive managed care providers have recognized that CDS can achieve the same results as pre-authorization programs without creating friction for physicians or providers. In several cases to date, Payers have exempted physicians who use CDS as part of their routine ordering process. Payers, physicians and providers are now working together to implement CDS solutions which achieve the goals of high quality and appropriate use of imaging, while maintaining an efficient and effective workflow.

 
 
For questions, comments or more information about this newsletter, please contact Medicalis at
1-877-579-5454 or info@medicalis.com
 
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About Medicalis
Medicalis is a leading provider of radiology workflow and decision support solutions, transforming the process of ordering and delivering diagnostic services. Providing critical healthcare information and evidence-based medical knowledge at the point-of-care, Medicalis solutions validate clinical orders and promote cost-effective quality in diagnostic healthcare. Medicalis solutions create a vital communication link between physicians, radiology and managed care.
 

 


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