Physicians in specific U.S. states must now request permission to perform MR and CT scans on patients insured by Anthem Inc. as part of a new program set up by the Indiana-based company.

The Imaging Clinical Site of Care program directs patients to free-standing imaging centers when it deems hospital outpatient imaging services medically unnecessary, with Anthem asserting that the program helps members save money and keeps premiums for health plans at an affordable rate.

“When it’s not medically necessary for members to receive the services from hospitals, they can receive their imaging tests from a free-standing clinic,” Lori McLaughlin, a spokesperson for Anthem, Inc., told HCB News. “In those cases, these members 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.”
The program first went into effect at the beginning of July for patients with local plans in Indiana, Kentucky, Missouri and Wisconsin. It will start on September 1 in Ohio, Colorado, Nevada, Georgia and New York and expand to Connecticut, Maine, and Virginia on March 1, 2018.

The premise of the program adheres to the principals of the Institute for Healthcare Improvement (IHI) Triple Aim Initiative, which advocates for the improvement of care in the patient experience, the improvement of population health, and reducing costs per capita in health care.

Under the new setup, doctors must submit precertification requests for MR and CT scans with Anthem, assessing whether the procedure is medically necessary for the patient and if the facility provides a level of care that meets certain criteria based on information collected by AIM Specialty Health, a specialty benefits management company. The criteria applied to providers and imaging centers include facility specifications, technologist and physician qualifications, accreditation and equipment.

If a procedure is approved but the hospital is deemed not worthy, the service will be denied and the physician will be sent a list of acceptable free-standing imaging centers where the procedure can be performed.

Physicians may appeal if they disagree with a denial, or go ahead with the procedure as planned, though the provider would incur the costs, according to Anthem's regulations.

Previous approved facility authorizations on file will be upheld until their expiration dates. Pediatric members also fall under this new guideline.

In a statement, the American College of Radiation criticized the decision, saying that it "compromises the physician-patient relationship" and creates unnecessary problems in the process of treatment.

"Denying patients covered access to care at such a vast number of facilities will delay care, increase wait times and force many patients to travel outside of their communities to get advanced imaging," it said in an official statement.

The program does not apply to clients under BlueCard, Medicare Advantage, Medicaid, Medicare Supplement or Federal Employee Program (FEP) plans, beneficiaries of an administrative services only (ASO) benefit plan, or those covered by DaimlerChrylser, Delphi, Ford Motor Group or General Motors.

CT Homepage