As of Sept. 1, Anthem will no longer pay hospitals in five states for outpatient imaging services for MRIs or CT scans.
Anthem already initiated its policy in four other states on July 1.
Imaging is a big part of hospital revenue, and Anthem said it costs more to have the service done in a hospital outpatient setting than at a freestanding facility.
"Anthem's primary concern is to provide access to quality and safe healthcare 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," Anthem spokeswoman Lori McLaughlin said.
Hospitals in New York, Ohio, Colorado, Nevada and Georgia will be affected starting Friday. Hospitals in Indiana, Kentucky, Missouri and Wisconsin have been under the policy since July 1, when Anthem started what it calls its Imaging Clinical Site of Care program. It is administered by Anthem subsidiary, AIM Specialty Health, for its individual and employer-sponsored members in fully insured programs.
Imaging services can be just as safely provided in a lower cost, free-standing center as in a hospital outpatient setting, according to Anthem.
Anthem's program also helps identify when hospital outpatient services for certain imaging tests are medically unnecessary, the company said.
Anthem's policy follows a move in July by the Centers for Medicare and Medicaid Services to make hospital outpatient payments more site neutral. Procedures performed at hospital outpatient departments are paid at a higher rate through the hospital outpatient prospective payment system,than freestanding clinics, which are paid on the Medicare physician fee schedule.
CMS said it would reduce outpatient prospective payment system spending by approximately $500 million in 2017 by no longer paying for outpatient services at a higher rate.
In the divide between pricing and payer reimbursement, providers nationwide may be concerned that other insurers will follow the lead of a large insurer such as Anthem.
"Hospitals need to recognize they are competing in a market already delivering on convenience, quality and affordability," McLaughlin said.
Anthem said the program gives members an opportunity to save up to hundreds of dollars for each imaging test.
The cost for MRIs and CT scans can vary from $350 to $2,000, Anthem said in 2010 when it launched its imaging cost and quality program to help educate members about their options in choosing high-quality, lower-cost imaging services.
Yet a recent report shows that many consumers don't make any attempt to compare prices for healthcare services. Most survey respondents said they didn't comparison shop or even ask how much they would owe in copayments or other cost-sharing expenses before they turned up for an appointment.
In cases in which it's not medically necessary for a member to receive services from a hospital, members who go to a freestanding facility 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, Anthem said.
Members who have high-deductible plans and haven't yet met their deductible may be responsible for the full cost of the service. In these cases the member saves the difference between the hospital imaging cost and the non-hospital cost, Anthem said.
Other members will pay a co-insurance usually of about 20 percent on the full cost of the service. Plans pay the other 80 percent.
If a member chooses to go to an outpatient hospital facility, and that in-network facility provides the service, it would be the provider, and not the patient, who would be responsible for the cost, according to Anthem. The member would only be held responsible for the cost of the service if he or she signs a waiver, agreeing to be responsible, Anthem said.
Hospitals would then bear the cost of their imaging services provided at outpatient facilities, for beneficiaries covered by Anthem insurance.
Anthem's exceptions to its policy include: when the services being provided are only available in the hospital setting, the individual requires an obstetrical observation, or the individual is receiving perinatology services. Also, exceptions are in cases where there is no other geographically accessible site, moderate or deep sedation or general anesthesia is required and a freestanding facility does not have this available; the equipment for the size of the individual is not available, or the individual has a documented diagnosis of claustrophobia requiring open magnetic resonance imaging which is not available in a freestanding facility.
AIM collects data on imaging providers, both hospital-based and freestanding, to determine conformance to industry-recognized standards, Anthem said. Providers and staff have access to each facility's score in an AIM portal, and can use those scores to find facilities.