The health insurance giant Anthem Blue Cross and Blue Shield is planning to change its guidelines for reimbursing imaging services like MRIs and CT scans, favoring freestanding outpatient clinics or imaging centers over hospitals.
In a statement, the company said a subsidiary, AIM Specialty Health, will help “identify when hospital outpatient services for certain imaging tests, such as MRIs and CT scans, are medically unnecessary,” in which cases members can receive those services — frequently used to help in the diagnosis process — at free-standing centers instead.
Anthem’s new guidelines already have launched in some states, and will roll out in Virginia, California, Connecticut and Maine on March 1.
Anthem is Virginia’s largest health insurer, covering nearly 3 million residents. As of the end of 2016, it held about 34 percent of the state’s accident and sickness insurance market, according to the State Corporation Commission.
According to the insurer’s statement, the rationale for making the guideline changes, first reported by The Virginian-Pilot, centers on cost — both for the insurer and the member in out-of-pocket expenses.
“The clinical guideline gives members an opportunity to save up to hundreds of dollars for each imaging test,” the statement reads. “It also helps health plans keep premiums more affordable.”
Typically, imaging services are more expensive at hospitals versus physician offices, according to Virginia Health Information. In central Virginia, an MRI of a knee cost $597 at a physician office in 2015, compared with $1,678 at a hospital. A CT scan of an abdomen cost $385 at a physician office and $1,233 at a hospital.
But not everyone thinks the cost is a strong enough reason to make these changes.
Julian Walker, spokesman for the Virginia Hospital & Healthcare Association, said in a statement that limiting where patients can receive care can lead to care fragmentation, and a more convoluted and confusing process for patients.
“Decisions about advanced imaging tests that patients need to diagnose and treat an illness or injury should be made with patient interests in mind,” Walker said. “Decisions by insurers to restrict where patients are permitted to receive a necessary medical procedure fail to meet that standard.”
In a statement, a VCU Health spokeswoman echoed Walker’s sentiments about the risk of fragmented care, saying, “Evidence-based medicine supports the practice of coordinated care, which could be threatened by requiring patients to only receive services from select unrelated providers.”
A Bon Secours Richmond Health System spokeswoman said in a statement that the health system is in discussions with Anthem to understand how the policy will be implemented, adding, “Bon Secours firmly believes the selection of the proper setting for imaging services should be a medical decision, rather than a business decision.”
When asked for comment, HCA Virginia directed inquiries to the Virginia Hospital & Healthcare Association.
The American College of Radiology, a professional medical society headquartered in Reston, issued a statement about Anthem’s guideline changes, calling them “arbitrary and unwise.”
“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,” the group said. “The policy may particularly impact patients in inner city and rural areas. In many areas, the local hospital outpatient setting may be the only immediate access point for advanced imaging outside of the main hospital.”
Anthem said in its statement that the guideline changes will apply only where there are at least two alternative free-standing imaging centers available to members, and acknowledges that some rural areas may not have those options available to them, in which case the imaging would be approved at the original location.