Health insurer Cigna has issued a new policy, stating that it won’t cover MR and CT imaging at hospitals unless the scans fit the insurer’s definition of medical necessity.
The nation’s fourth largest private payer detailed a small list of exceptions, including if a patient is less than age 10, has a contrast agent allergy or if there are no alternative imaging sites. Absent such circumstances, the Connecticut-based company is steering its beneficiaries to standalone centers where providers charge considerably less.
“Freestanding imaging facilities may offer Cigna members a lower cost alternative than a hospital-based imaging department or facility for medically necessary, nonemergent imaging procedures,” the company said in its announcement.
Cigna isn’t alone in making this move. For instance, Anthem, the country’s second biggest payer, implemented a similar policy in 2017. At the time, company officials said some patients could save upward of $1,000 out of pocket for some imaging services by opting to visit a freestanding center. One analysis that year estimated that MR and CT imaging could cost upward of 149% higher at a hospital compared to a freestanding center.
The policy is set to take effect on April 14, with Cigna reviewing its implementation in June, according to the announcement. Certain plans administered by the company also have the ability to exclude their members from this policy. Other exclusions include if outside imaging could adversely impact care, or a patient has been diagnosed with claustrophobia and requires open-air MRI that is not available at a freestanding site.
Insurers dictating when imaging is medically necessary is nothing novel. However, their prescription of where radiology services are delivered is a newer phenomenon, noted Kathryn Keysor, senior director of economics and health policy for the American College of Radiology. For radiologists, the takeaway is to stay abreast of payers’ policies related to site-of-care medical necessity, and pinpoint exceptions where possible.
“Most insurers will consider a patient’s individual circumstances—e.g., mobility and transportation options—when making a determination,” she told Radiology Business. “The ACR will continue to work with insurers on a national level to ensure that quality patient care is the primary priority.”
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.