A large national health plan was experiencing significant inappropriate advanced imaging utilization in a Northeast market.

Not only were utilization levels substantially higher than national averages, but utilization was also growing ~20% annually.

If no action were taken, this growth would necessitate higher premiums which could negatively affect the health plan's competitiveness in the market.

Within three months of implementing a prior consultation program, NIA immediately reduced MRI utilization rates by 30% (Exhibit D). After this strong first year performance, NIA also held growth to half its previous rate in year two (Exhibit B).

Overall, prior consultation achieved savings of ~1.33 in year one and ~2.08 in year two (Exhibit C) for MRI/A, NC and PET alone (CT was managed under a separate program).

Exhibit A -
Pre-Implementation Advanced Imaging Utilization Growth Rates by Modality Percent

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Exhibit B -
Advanced Imaging Utilization Trend Comparison Percent

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Exhibit C -
Year 1 Estimated Program Savings Dollars Per Member Per Month

Year 2 Estimated Program Savings Dollars Per Member Per Month

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Exhibit D -
Comparison of Management Strategies Effect on Utilization of MRI/A
(Annual Procedures Per 1000 Members)

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