The Blues giant Anthem will no longer pay for MRIs and CT scans performed on an outpatient basis in hospitals across the country. Anthem is taking aim at a service line that can be far more expensive in a hospital than in a free-standing imaging center.
For its fully insured members, Anthem will no longer pay for MRIs or CT scans delivered at hospitals in nine states this year, unless a review finds it was medically necessary to perform the scans at a hospital, which will be unlikely. The policy will be rolled out to all but one of the 14 states where Anthem does business by March 2018, ultimately affecting 4.5 million members, according to an Anthem spokeswoman. New Hampshire is the exception. Patients must go to a free-standing imaging center instead of a hospital for these services. Anthem said the policy doesn’t affect patients enrolled in government programs, such as Medicare and Medicaid, or those with self-funded employer coverage.
Anthem’s refusal to cover an important medical service at hospitals marks the beginning of the next wave of tension between payers and hospitals, with radiologists caught in the middle. Anthem said the policy went into effect in Indiana, Kentucky, Missouri and Wisconsin on July 1st, and it will start in Colorado, Georgia, Nevada, New York and Ohio on Sept. 1st.
More health insurers are expected to implement broad-based payment policies like Anthem’s imaging program as they look for new ways to cut costs, hold down premiums, and make their margins.
Radiologists are concerned that if the hospitals continue to perform these services on these patients, due to inadequate screening or precertification, and the radiologist is required to interpret the images, they will be doing so for free because Anthem with deny payment on the back end. It could mean more radiologists will likely end up going through a lengthy and convoluted appeals process with a low likelihood of success.
The imaging site-of-care policy comes on the heels of Anthem’s announcement earlier this year that it will no longer pay for emergency room visits in non-emergency situations. That policy, meant to push patients to get care from primary-care doctors or in retail clinics, is effective in at least three states.
As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.
Kirk Reinitz, CPA