Overutilization in Healthcare is a problem which has been estimated to cost in the range of hundreds of billions of US dollars every year.  Despite historically spending more than double per person on healthcare than the average developed country, our outcomes have not been significantly better ⁽¹⁾. To improve, specialty organizations publish clinical quality initiatives and practice guidelines that support consistent, focused, evidence-based care.

The American Board of Internal Medicine (ABIM), through its Choosing Wisely Campaign, to reduce the use of tests and procedures that add no value to patient care, generated a list of 5 evidence-based recommendations from each specialty society about potentially unnecessary medical testing and procedures.  One recommendation focused on limiting the estimated 20% to 50% of high tech radiologic imaging ordered by health care providers thought not to be of value to the patient suffering from nonspecific low back pain of short duration.  Diagnostic imaging is not routinely of value in this clinical scenario; it carries direct waste due to the expense of this primary imaging.  In many instances, clinically insignificant abnormalities found in initial imaging also drive more advanced follow-up imaging.  A third aspect of waste here, at least significant with the CT imaging subset, is the risk over time of exposure of a significant number of patients to unnecessary ionizing radiation.  Finally, using imaging resources where they are not of value can adversely impact access to these services where they are otherwise needed ⁽²⁾. 

Payers of CT/MRI of lumbar spine should monitor for atypical medical necessity patterns submitted in high frequency with nonspecific primary ICD-10 codes like S39.012A (Strain of lower back, initial encounter).  If as a payer you find a high proportion of such non-specific primary ICD-10 codes in a random sample of CT/MRI of lumbar spine studies, you should next look for a pattern of overuse, to see if it relates to a specific ordering physician, performing physician, provider group, etc. 

The most adaptive payers Identify significant inappropriate utilization patterns and then drill down on the details to understand why.  If an inappropriate pattern is found, the payer may need to adapt internally, by developing a policy to outline appropriate medical necessity for the service or update a key policy already in existence.  When internal policies are already clear and appropriate, denial with request for medical records or letter of medical necessity might be appropriate response when more information is needed and frequency of nonspecific dx code use is not aberrant.  Rampant patterns of overuse of high dollar imaging with non-specific ICD-10 codes point to a more significant overuse issue.

Context4 Healthcare is constantly updating our Fraud, Waste and Abuse software. We continually monitor for emerging inappropriate utilization patterns.  We use these emerging patterns, as well as information from OIG and specialty organizations, to constantly adapt and adjust our solution.  With the use of the Context FWA solution, we can help you identify significant patterns that impact your unique payer environment.  You can analyze and drill down on these patterns with our appropriate edits and reports.  They can help you adapt quickly and avoid inappropriate overpayments due to overutilization.

REFERENCES

1. Ezekiel J. Emanuel, MD, PhD; Victor R. Fuchs, PhD, The Perfect Storm of Overutilization,

   JAMA. 2008;299(23):2789-2791. doi:10.1001/jama.299.23.2789

2. Litkowski, P, Smetana, G, Zeidel, M, et al, Alliance for Academic Internal Medicine (2016) 129, 1131-1135