Post#3 The Second Key to the (Prior Authorization) Castle – Evidence-Based Guidelines

In the previous blog I described how the intake process begins with the prior authorization (PA) nurse asking 8-10 clinical questions to the physician's PAL (prior authorization liaison).  The nurse types the answers to the clinical questions into the patient’s database and, at the same time, is looking at a set of guidelines for reference. The nurse is not the only one who use these guidelines: Medical Directors also make use of this document with every case review and with every peer-to-peer (P2P) call. 

The second Key to the castle is: “Evidence-based Guidelines: USE them whenever you are uncertain as to which imaging study to order.”

During the 7 ½ years I served as a medical director, the most common question I was asked during  P2P calls was “Where did those guidelines come from?” The answer explains why RBM guidelines are such a valuable resource, not only for obtaining a quick authorization but also for providers who want to practice evidence-based medicine. Although I worked for only one RBM company, I have discovered that all the major RBMs create their own guidelines and use them to make approval decisions.

Radiology Benefits Manager's Guidelines come from the Guidelines created by National Medical Organizations,  including:

 -American College of Physicians                      -American Academy of Pediatrics
-American Academy of Family Practice            -American College of Radiology
-American College of Radiology                        -American Urological Association
-American Association of Sleep Medicine        -American Academy of Neurology
-National Comprehensive Cancer Network      -American College OB-GYN
-American College of Cardiology                      -and many more ...
 

These guidelines are well researched, high-quality, and evidence-based, but most of them are too lengthy to be useful in the clinic setting. For example, one guideline for Ischemic Heart Disease is over 200 pages.  In fact, if all the medical guidelines from all the national organizations were combined, the result would be a document well over 100,000 pages!

Radiology Benefits Managers condense the data from over 100,000 pages of guidelines by focusing only on imaging and excluding other clinical data. The result is a document of less than 1,000 pages with guidelines that specifically focus on diagnostic imaging and cover all of Medicine and Pediatrics. Most guidelines are less than a printed page while some are as short as a single paragraph.   Some guidelines are in a table format, and may contain just a few words.

For most RBMs, guidelines from National Specialty Organizations are combined with evidence from the recent medical literature and input from both specialty review panels and independent subject matter experts.  RBM guidelines are monitored and updated at least yearly.  They serve as the company’s “Bible” to support prior authorization decisions.

Best of all, these guidelines are accessible and free

Guidelines are available in PDF format on the RBM’s website, and can be copied and pasted onto your desktop for reference any time.  At the end of this blog posting are instructions on how to capture these guidelines on your computer for your own use.  

You might not need to refer to the guidelines with every imaging study you request, but they can be helpful whenever you are uncertain as to which test to order.

RBM guidelines can also tell you if there are any prerequisites that should be completed before requesting an imaging study (for example, a plain chest x-ray before some chest CTs or 6 weeks of unsuccessful conservative treatment before a shoulder MRI).

  Take Home Lesson:  Use the Evidence-based guidelines provided by any large RBM as your medical imaging playbook.  Find the guidelines on the RBM website, Copy and Paste PDF files to your desktop, and refer to them when you are uncertain. 

How to capture guidelines:

evicore

https://www.evicore.com/--> Click on "Clinical Guidelines and Forms" --> Select Solution --> Cardiology & Radiology.  Adult and Pediatric guidelines are separate. 

Click on each guideline, hold down mouse and move to your desktop.

American Imaging Management (AIM) Guidelines

Http://aimspecialtyhealth.com/CG-Radiology.html

Click on each guideline, hold down mouse and move to your desktop.

 National Imaging Associates (NIA) Magellan Health Services:

http://www1.radmd.com/radmd-home.aspx

Scroll down to More Online Tools. Click on "2018 Clinical Guidelines" hold down mouse and move to your desktop. 

 

To remain up-to-date, remember to update your desktop copy of the guidelines when RBMs publish a new version each year.  If you sign up to this website, we will notify you when a new version of the guidelines is available:   www.avoidingpeertopeercalls.com