Ama Policy

Radiology Benefits Manager H-320.946

U.R. Criteria

Our American Medical Association:

(1) strongly encourages radiology benefits managers (RBMs) to adhere to uniform physician-developed best practice guidelines;

(2) supports the use of appropriate use criteria developed by physicians with relevant expertise working in a collaborative process involving all national medical specialty societies that provide and/or order the imaging service in question;

(3) supports an independent study assessing the magnitude of the cost and administrative burden of imaging utilization strategies on ordering physician offices, imaging providers, and patients and the impact these strategies have on patient safety and outcomes;

(4) strongly encourages each radiology benefit manager (RBM) to publish and distribute the specific diagnostic codes used by their firm to approve or disapprove specific imaging procedures. This information should be distributed by the RBM via electronic or paper means to each physician who is credentialed to participate on health plans that utilize that particular RBM;

(5) opposes the practice of forced test substitution and arbitrary denial of requested imaging services by RBMs contracted by third-party payers that meet appropriate use criteria, and that RBMs be held accountable for harm caused by substitution or delay of requested studies; and (6) encourages the Physician Consortium for Performance Improvement to continue to develop patient-centered measures, including those that address the appropriate use of imaging.

Policy Timeline

CMS Rep. 5, I-09 Reaffirmed: Res. 709, A-12 Reaffirmation A-15