Anthem's new limits on claims for imaging services, a profit center, could hurt rural hospitals

Imaging services can be much less
expensive at free-standing imaging
centers than at hospitals. Click on 
image to enlarge. (Amino graphic)

Health insurance giant Anthem Inc. says it will no longer pay for most privately insured outpatient MRIs and CT scans in hospitals unless a review finds it was medically necessary, Shelby Livingston reports for Modern Healthcare. Other insurance companies may follow if the market reacts favorably.

Anthem says the change will not affect anyone relying on Medicare, Medicaid or self-funded employer coverage. Other patients will have to go to a free-standing imaging center, where imaging services can cost half as much as in hospitals. Hospitals charge more for imaging to cover significant overhead costs.

The policy could hurt rural hospitals that are already struggling to stay open. It may cause problems for rural residents too, since they may not have easy access to free-standing imaging centers.

Anthem has tried to protect and increase profits by withdrawing from some states; this appears to be the next step in cutting costs and marks the "beginning of the next wave of tension" between payers and hospitals, says health-care industry consultant Paul Keckley.

Hospitals don't much like the new policy, for reasons beyond the loss of profit. Brian Tabor, president of the Indiana Hospital Association, told Livingston the policy will force doctors to spend more time "fighting for reimbursement" and going through lengthy appeals processes for patients who had imaging done in the hospital. That could cause hospitals to have to spend more money on staff. Scott Wallace, an associate professor at the University of Texas' Dell Medical School and managing director of the school's Value Institute for Health and Care, says the policy will increase bureaucracy and make care coordination more difficult.

While patients could possibly endure delays in care, "in general this is going to be a benefit for patients, assuming they have a place to go," says Lea Malin, senior consultant of research with the healthcare research outfit The Advisory Board Co.

"The policy went into effect in Indiana, Kentucky, Missouri and Wisconsin on July 1, and it will start in Colorado, Georgia, Nevada, New York and Ohio on Sept. 1," Livingtston reports. By March 2018, Anthem will roll out the new policy to all 14 of the states it serves, except for New Hampshire. An Anthem spokesperson said the new policy will affect 4.5 million people.