Close on the heels of its controversial policy aimed at placing constraints on emergency room visits (HPW 7/24/17, p. 4), which has met with resistance, Anthem, Inc. is implementing another coverage policy based on “medical necessity.” This time it’s for hospital-based outpatient imaging across its Blue Cross and Blue Shield plans in 13 states. The upshot is that the Indianapolis-based health insurance giant won’t pay for certain imaging tests done on an outpatient basis in hospitals that the insurer asserts could be done in less costly settings. The move is getting strong pushback from radiologists amid their concerns that other insurers may follow suit.

“Our Imaging Clinical Site of Care program, administered by Anthem subsidiary AIM Specialty Health, started in Indiana, Kentucky, Missouri and Wisconsin on July 1 for our individual and employer-sponsored members in fully insured programs,” Lori McLaughlin, Anthem’s communications director, tells AIS Health. “It will roll out to Ohio, Colorado, Nevada, Georgia and New York on Sept. 1; California, Oct. 1; and Connecticut, Maine and Virginia on Mar. 1, 2018. The review will be offered to local, self-funded accounts to add to their members’ benefit package on Jan. 1, 2018.”

Under Anthem’s new coverage policy, the doctor or medical practice must submit a prior authorization request for outpatient MRI or CT services at the hospital. The imaging service will be covered at the hospital only if Anthem deems the request to be medically necessary. According to Anthem, an advanced radiologic imaging procedure in the hospital outpatient department is considered medically necessary when the services being provided are available only in the hospital setting; the individual requires an obstetrical observation; the individual is receiving perinatology services; or there are “no other geographically accessible appropriate alternative sites” for the individual to undergo the procedure. Anthem says the last category includes, but isn’t limited to: when moderate or deep sedation or general anesthesia is required for the procedure and a freestanding facility providing such sedation is unavailable; when the equipment for the size of the individual is unavailable in a freestanding facility; or when the individual has “a documented diagnosis of claustrophobia” requiring open magnetic resonance imaging unavailable in a freestanding facility.

If a member chooses to go to an outpatient hospital facility and that in-network facility provides the imaging service, then the provider, and not the patient, would be responsible for the cost, according to Anthem. Members would bear the cost only if they sign a waiver.

ACR Calls Policy ‘Arbitrary and Unwise’

McLaughlin tells AIS Health that “the program covers CTs and MRIs only.” But the American College of Radiology (ACR), in an Aug. 29 statement, considers the policy to be more broadly applicable. “The new Anthem cost-cutting policy of not covering advanced imaging (MRI, CT, PET, etc.) performed in hospital outpatient departments is arbitrary and unwise,” ACR says.

ACR says “economically motivated steerage of patients compromises the physician-patient relationship” and “sets up another nontransparent preauthorization process that moves medicine backward.” Inner-city and rural patients may be most adversely affected, it says, since they live in places where the local hospital outpatient setting “may be the only immediate access point.”

Anthem insists that its primary concern “is to provide access to quality and safe health care for our affiliated health plan members. We are also committed to reducing overall medical cost where possible when the safety of the member is not put at risk.”

McLaughlin explains Anthem’s rationale in this way: Clinical research shows the safety of providing imaging services in free-standing imaging centers. The program helps identify when hospital outpatient services for certain imaging tests are medically unnecessary. In such cases, members can get needed services in a clinically appropriate setting, such as a freestanding outpatient clinic, which is often less costly. Members could save up to hundreds of dollars for each imaging test and have more affordable premiums.

She cites “huge cost disparities” for imaging services, depending on where members get diagnostic tests. At a free-standing clinic, patients “can save close to $1,000 out-of-pocket for some imaging services for those who haven’t met their deductible and up to $200 for those whose plans require only a copay,” she says.

Anthem members in high-deductible plans who haven’t met their deductible may be responsible for the full cost of the service, she says. In those cases, the member saves the difference between the hospital imaging cost and the non-hospital cost. For other members with coinsurance, “the lower the cost of the service, the more affordable the cost is to members and plans,” she says.

Under Anthem’s imaging program, its AIM subsidiary collects data on imaging providers, both hospital-based and free-standing, in areas such as facility specifications, clinician qualifications, accreditation and equipment. Information is used to determine conformance to industry-recognized standards and to assign a site score. Providers can use AIM’s portal to see each facility’s site score and find facilities with equivalent scores.