Benefit Management
Automated radiology appropriateness, applied before payment
Catch low-value routine imaging that traditional payment integrity edits miss, without adding prior authorization, slowing care, or straining your provider relationships. Built for health plans that want to manage high-volume routine radiology the same way they manage routine lab.
Why this matters
Up to 30% of medical imaging is considered low-value or unnecessary. That’s spend without clinical benefit to the member.
Four of the five most common low-value services among Medicare beneficiaries are radiology. Routine imaging is a primary driver of waste.
99.4% of internists report cascades of care from incidental findings. Unnecessary imaging triggers downstream tests, costs, and member anxiety—and 33.7% acknowledged the initial test may not have been appropriate.
Every avoidable study adds cost, radiation exposure, and member burden. Preventing it is far more effective than recovering it later.
$100B
spent annually on U.S. medical imaging
~30%
of imaging provides little to no clinical benefit
4 in 5
of common low-value services in Medicare are routine radiology
The gap in your imaging strategy
$1
per member per month savings potential
Most health plans have advanced imaging covered. Radiology benefit managers gate the expensive decisions: CT, MRI, PET, through prior authorization and clinical review. Payment integrity vendors confirm that claims are coded and billed correctly.
But routine radiology sits between the two. X-ray, ultrasound, and non-cardiac nuclear medicine are low-cost and high-volume, so they fall outside the scope of RBM programs. And payment integrity validates how a claim was billed, not whether the imaging should have happened at all.
That leaves a large category of spend essentially unmanaged. Routine Radiology Management closes the gap.
Intelligent policy edits in action
We translate rigorous scientific guidelines into automated claim edits based on fixed criteria — allowing us to evaluate claims instantly and accurately. Each policy incorporates multiple, layered enforcement criteria to ensure clinical appropriateness.
Our proprietary approach targets both overutilization and inappropriate utilization, protecting members and plans from unnecessary cost and clinical risk.
Real-world example:
Pre-operative chest x-ray (CPT 71046)
| Approach | Outcome |
|---|---|
| Routine Radiology Management | Claim denied, post-service and pre-payment, via procedure-to-procedure compatibility |
| Radiology Benefit Manager | Claim paid, not eligible for prior authorization |
| Payment Integrity | Claim paid, edits focus on coding and billing integrity |
Same claim. Different result. Appropriateness logic is what catches it.
How Routine Radiology Management works
A four-stage process that transforms fragmented workflows into a highly scalable, evidence-based program — without disrupting care delivery.
Three core policy sets cover the space: routine radiography, routine sonography, and routine nuclear medicine.
01
Scientific policy development
We build radiology-specific clinical policies grounded in published, transparent guidelines, supported by a dedicated Clinical Advisory Board.
02
Automated policy edits
Policies become rules: procedure-to-procedure compatibility, procedure-to-diagnosis compatibility, frequency limits, and age requirements.
03
Engine integration
Our policy engine integrates with your claims systems for real-time, pre-payment claim editing.
04
Analytics and reporting
You get per-provider impact reports, outlier identification, and clear visibility into savings and adherence.
Ready to see what routine radiology is costing you?
Routine Radiology Management is built for health plans that want to manage routine imaging: automatically, at scale, and without member friction.
Let’s run the numbers on your data and show you the opportunity.