The saga of precertification for echo goes on. I see three basic patterns evolving across the country that I will attempt to summarize below:

1. “I'm mad as hell, and I'm not going to take it anymore.” The Delaware Chapter has been successful in illustrating to the public and Congress the harm that can come to patients when a Radiology Benefits Manager (RBM) comes between the patient and their cardiologist. There are not only flat denials, but delays and mandated substitutions, such as stress echo instead of stress nuclear. The scientific data regarding the specificity and sensitivity of these particular tests has been transmogrified into a position that the two tests are always interchangeable and are equivalent. RBMs demand substitution of echo for MPI without detailed knowledge of the clinical situation. These intrusions into patient care are inappropriate and unacceptable.
   
   
2. “Cardiologists, enabled with tools to insure the appropriate use of imaging, can do this better than a RBM.” Several chapters, working with local payers, are looking at testing regional programs that would use an ACC FOCUS tool in place of RBMs. The FOCUS tool would provide cardiovascular imaging strategies based on ACC appropriate use criteria and could ultimately serve as national models -- rational, data driven and less intrusive than a 20 minute call to the RBM for precertification of an outpatient echo.
   
   
3. “We just have to grin and bear it.” Some practices are simply reconciled to the fact that insurance companies will impose regulations that are not value added to the patient or the practice, but must be endured. These practices are adding additional precertification staff, streamlining their processes, and "playing the pre-cert game" to take the process from a 20 minute one to a 5 minute one.

Where does your practice fit? I suspect that there may be a blend of all three approaches in most practices. Personally, I have tried to streamline the pre-cert process, while resisting the most egregious denials by the RBM. I look for the ACC, as my professional society, to provide me with a tool that will allow me to demonstrate my appropriate use of imaging with minimal workflow hassles in the office. This tool is in the works, so stay tuned for more information.

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