Imaging advocates are asking commercial insurer Anthem to reconsider a payment restriction they believe will have a detrimental impact on patient care.
The American College of Radiology and Society for Pediatric Radiology expressed frustration with the Indianapolis-based payer in a recent letter. Their “significant concerns” stem from an Anthem policy that directs children age 10 and older away from hospital-based imaging departments.
They’re asking Anthem to revise medical necessity criteria, allowing kids up to age 19 to undergo high-tech imaging procedures such as CT and MRI at hospital-based sites. This would grant patients access to experts in pediatric imaging, the two argued.
“We believe this policy has a profoundly negative impact on the quality and safety of pediatric care for children and adolescents undergoing advanced outpatient imaging studies,” ACR and SPR wrote in an April 22 letter to John Whitney, MD, Anthem’s VP of medical policy. “We strongly believe that pediatric specialists make a substantial difference in the safety accurate clinical decision-making and, most importantly, improve outcomes for the pediatric patient,” the groups added later.
ACR and the pediatric society called the 10-years-old cutoff arbitrary, noting that many childhood diseases extend into adolescence. They’re asking Anthem to reimburse for such nonemergent, high-tech imaging in hospitals for patients up to age 19. Other insurers, such as Cigna and UnitedHealth, have amended their site-of-care imaging policies to include children in this age group, the letter writers noted.
“Economic steerage of pediatric patients, disregarding their optimal care, is neither appropriate nor in the patient’s best interest,” the letter concluded.
Anthem was one of the first in a line of health insurers to implement restrictions around hospital-based imaging, hoping to steer patients toward cheaper freestanding options. ACR alerted members about this issue in an update published Thursday.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.