Anthem policy pushes outpatient imaging out of hospitals

Anthem made headlines this summer by pulling back from several Obamacare exchange programs, but that’s not the insurance giant’s only big policy change of 2017. The Imaging Clinical Site of Care program, administered by Anthem subsidiary AIM Specialty Health, requires outpatient MR and CT scans not considered medically necessary to be completed at a freestanding imaging facility in order to be covered.

The program went live in Indiana, Kentucky, Missouri and Wisconsin on July 1 and it moves on to Ohio, Colorado, Nevada, Georgia and New York on Sept. 1. Orders are placed by the physician and then, if the scan is not considered necessary, a provider portal suggests potential imaging center locations where the patient could go.

According to an Anthem spokesperson, patients benefit from this new program because they will save on each scan and it will help keep health plan premiums lower.

Industry buzz around the action has been getting louder in recent days. The American College of Radiology (ACR) has no official statement at this time, but one could be forthcoming. RSNA has indicated it will not be making a statement. 

On the provider side, concern is high. While patients are top of mind, so is the health of the imaging business. In Indiana, where the Imaging Clinical Site of Care program has been in place for nearly two months, private practices are already noticing a significant change in the marketplace. Linda A. Wilgus, CPA, CMPE, executive director and CFO of Northwest Radiology Network in Indianapolis, said she ran a quick analysis of the company’s workload since July 1 and noted a significant decrease in high-tech imaging from hospitals.

“We’re watching this very closely, and we have concerns about this policy,” she told Radiology Business. Wilgus added that, as a full-service radiology provider, Northwest Radiology Network completely understands “the importance of having financially stable hospital systems to serve communities.” However, she said, the concerns remain and her team will continue to keep a close eye on how this policy affects the marketplace. “We’re making sure we understand the impact this has on our private practice of radiology, both as we provide services in the hospital setting and in our outpatient setting,” she said.

David Levin, MD, professor and chairman emeritus in the department of radiology at Jefferson Medical College in Philadelphia and Thomas Jefferson University Hospital in Philadelphia, said the Imaging Clinical Site of Care program represents “a very short-sighted policy on Anthem’s part.”

“They should not be tampering with referral patterns in this way,” Levin told Radiology Business. “It can be an important quality issue in many parts of the country, where the best radiologists are those working in hospitals.”

Levin also expressed concern that this could leave rural patients with limited options when it comes to finding sufficient care. According to Anthem, if there are “no other geographically accessible appropriate alternative sites for the individual to undergo the procedure,” the scan can then be viewed as medically necessary and completed at the hospital.

Levin added that the program will harm hospitals as well.

“The policy will seriously impact hospitals, which often rely on high-tech imaging to bring in revenue that helps them cover the costs of other money-losing services,” Levin said. “There’s no doubt that hospital-based radiologists also will be hurt, and I think they and the ACR should strongly protest this to Anthem.”

Levin said Anthem could have instead looked into reducing reimbursement to hospitals for MR and CT scans “to a point at or perhaps slightly higher than what they pay to private centers.”

Radiology Business will continue to cover this story.