For years, hospitals have been overcharging patients for diagnostic imaging, while imaging centers have offered lower prices. Insurance companies are finally starting to notice this trend, and in fact, Anthem, the second largest insurance company in the country, has recently announced that it is reducing the number of diagnostic imaging claims it accepts from hospitals.
The insurance giant cited the difference between the MRI cost and CT scan cost at hospitals versus free-standing clinics as the reason behind the shift, and this insurer isn’t the only one to make this type of move in recent years.
Anthem’s New Policy
According to Anthem, the insurer won’t necessarily turn down claims from diagnostic imaging that takes place at hospitals, but it will only accept those claims if they are medically necessary. In all other cases, patients should go to an imaging clinic.
In order to be considered medically necessary, imaging at a hospital needs to meet at least one of the following list of criteria:
- The services are only available at a hospital. In other words, the sames services are not available at a freestanding clinic.
- The patients is getting obstetric care of perinatology services.
- There is no other site in the area where the patient can get the same imaging.
Patients Affected by the Changes
The changes affect patients in nine different states in the country. That includes Indiana, Kentucky, Missouri, Wisconsin, Colorado, Georgia, Nevada, New York, and Ohio. However, patients in these areas may be affected differently. Anthem takes a number of elements into account when making decisions.
Similar Shifts in Medicare Policies
Medicare, the government-funded insurance program for seniors in the United States, has also made similar moves. This insurer has rolled out site-neutral pricing schemes. That means that if a patients gets diagnostic imaging, Medicare is only willing to pay one price. Generally, that price is closer to what gets charged at an imaging center, and it doesn’t even come close to the high prices charged at hospitals.
Why Imaging Centers Are More Affordable
Hospitals tends to charge more for imaging because they have to cover the parts of their business where they lose money. In particular, emergency rooms tend to lose hospitals money, and they often make up for those differences by adding money onto imaging bills or similar services.
In general, consumers are demanding more competitive pricing in more accessible settings, and hospitals simply cannot compete in this realm. Anthem advises hospitals to screen patients more tightly so they know whether or not their insurance is likely to cover the procedure. The insurer also urges doctors to refer patients to more freestanding clinics.
What Patients Should Do
If you are affected by these changes, you don’t want to accidentally be forced to cover a CT scan cost or an MRI cost out of pocket. To prevent that, you need to go to a diagnostic imaging center. At American Health Imaging, we have locations in several states for your convenience, and we can make sure your insurer covers the imaging before we get started.
If you are a doctor, you may want to refer your patients directly to us so that they are more likely to have the coverage them need. Contact us today to learn more.