Waste, Fraud and Abuse of Diagnostic Imaging Impact Patient Safety and Drive Overall Healthcare Spending

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, after sobering reports found that almost half a billion radiological procedures will be performed annually by 2008.  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 that leads to repetitive and duplicative procedures, the result is the performance of unwarranted studies, with attendant unnecessary costs, and in some cases risk to the patients involved.  ”

”The National Cancer Institute estimates 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 65 percent of the effective radiation dose from all medical x-ray examinations to the population,” says Dr. Allen.

Dr. Allen cites additional culprits that contribute to waste, fraud and abuse 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
• treatment of incurable diseases
• direct-to-consumer marketing
• physicians that are self-referring patients to owned in-office equipment in order to make a financial profit

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. 

return to the table of contents