June 6, 2013
Services help employees needing MRIs or CT scans get required approval, find reasonable price
Employees and family members covered on a Purdue medical plan who need high-tech imaging, like an MRI or CT scan, have two services to help them get the right test at a reasonable price: MedSolutions and Castlight.
Cigna uses a company called MedSolutions to review and approve imaging services. MedSolutions deals exclusively with the quality management of medical imaging services, working to assure that patients get the tests that will help enable an accurate diagnosis.
"Whenever possible, allow 48 hours between your doctor appointment and your imaging appointment so there's time to complete the required pre-approval of your test," says Eva Nodine, benefits director in Human Resources.
Nodine shares the following information about imaging coverage on Purdue's medical plans:
* Approval is required for all CT/CTA, MRI/MRA and PET scans and for nuclear cardiology imaging.
* Pre-test approval applies to outpatient imaging services that are elective or non-emergency.
* Post-test approval applies for emergency room, inpatient, 23-hour observation and outpatient emergency imaging services.
* Both pre- and post-approval are initiated by the patient's in-network ordering physician via the Internet or phone. For out-of-network services, either the ordering physician or the insured (employee) must initiate the approval process.
* Coverage approvals are processed within two business days after MedSolutions receives all necessary information, or within 24 hours, if expedited review is requested. MedSolutions will fax the approval notice to the ordering physician and to the patient's selected imaging facility. MedSolutions will notify the insured by mail. Authorizations are good for 60 calendar days.
* Coverage denials are faxed to the ordering physician and include the rationale for the denial, plus information on how to request a peer review. Many times the first denial is because MedSolutions did not receive the required clinical information from the doctor. MedSolutions will fax notice of the final determination to the ordering physician and will mail it to the insured.
* Peer review may be requested by the ordering physician. In these cases, MedSolutions will connect the ordering doctor with a physician reviewer to discuss the denial decision.
"The entire process is important to the patient because it helps ensure the patient receives the right test at the right time," Nodine says.
When considering imaging options that are appropriate for diagnosing the patient's condition, MedSolutions will ask that the tests exposing the patient to the lowest amount of radiation be used first.
"If these tests don't provide enough information for treatment, then tests with higher radiation exposure can be considered, as long as criteria are met," Nodine says. The process also helps physicians choose appropriate imaging services.
Castlight, Purdue's health care shopping tool, lets employees search for a high-tech imaging provider before going for a test. For example, a quick check of Castlight shows that an in-network MRI of the abdomen costs between $671 and $4,199 in the Lafayette-West Lafayette area, depending on the provider. For an employee covered by the Purdue Incentive who has already satisfied the plan deductible, that would mean a cost range for the employee of $134.20 to $839.80. "Shopping around can make a big difference for both the employee and Purdue," Nodine says.
If a patient anticipates the doctor will be ordering high-tech imaging for a particular condition, Nodine suggests checking Castlight before going to the doctor appointment. "Then, if your physician orders one of these services, you'll know which facility you want to use and can tell your doctor," she says.For more information, contact Human Resources at firstname.lastname@example.org, www.purdue.edu/hrhelp or 49-42222.