For those of you that aren’t already noticing this change, let’s talk about BCBS and their new policy of directing patients from the hospital out-patient setting and in to the waiting room of the free-standing imaging centers for all their advanced imaging needs.

To date, there are 14 states affected, but you may see more as time advances.  The Blues Giant Anthem has issued a new policy demonstrating where they will no longer pay for CT or MRI scans if performed in a hospital outpatient setting.  This is another attempt by this payer to contain rising healthcare costs, implemented by an Indiana-based administrator for Anthem, that was a former CEO for a health system.  This former CEO is targeting ways to contain rising healthcare costs by starting with advanced imaging needs.

Research has shown a significant savings for advanced imaging when performed in a free-standing imaging center versus a hospital out-patient setting.

Obviously, hospital administrators across the country are worried about their profit margins being negatively affected and at a time it hurts most.

How will this affect hospitals keeping their doors open?  How will this affect hospitals and their employee contracts with Radiologists?  How will this affect hospitals and their delivery of quality patient care?

For its fully insured members, Anthem will no longer pay for MRIs or CT scans delivered at hospitals in nine states this year, unless a review finds it was medically necessary to perform the scans at a hospital.

The policy will be rolled out to all but one of the 14 states where Anthem does business by March 2018, ultimately affecting 4.5 million members, according to an Anthem spokeswoman. New Hampshire is the exception.

In the other states, patients will have to go to a free-standing imaging center instead of a hospital for some services. Anthem said the policy doesn’t affect patients enrolled in government programs, such as Medicare and Medicaid, or those with self-funded employer coverage.

Anthem said the policy will help keep premiums low and gives patients an opportunity to save hundreds of dollars, especially those members enrolled in high-deductible health plans. 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.

In addition to the many questions of how this will affect hospitals, a whole new can of worms are opened as questions multiply.

Let’s talk patient care.  How will this affect patients? The patient will likely see a savings as well, since their out of pocket expenses will be more in line with the cheaper free-standing imaging centers pricing, when compared to hospital pricing.  If this new policy is successful, how many other payers will duplicate this policy?

Some of the experts in the medical industry agree the stakes are high by denying coverage and subsequent payment to hospital radiologists (and other physicians) for the imaging services provided for patients, while other experts in the medical industry agree the new policy is right on target with the direction in which the healthcare industry is headed.

It’s not a secret that radiology services are an intricate part of hospital services for all patient types including inpatient, outpatient and emergency room. The impact on hospitals could be significant.

This policy does NOT apply to government plans such as Medicare and/or Medicaid, nor does it apply to self-funded employer groups, but applies to all other fully insured members.  The exception to their fully insured members if when a review by an independent party finds it was medically necessary to perform the advanced imaging services at a hospital as opposed to a free-standing imaging center.  I don’t foresee any review meeting the criteria necessary to reverse this policy and subsequent payment.
However, Medical Business Office, Inc. as your professional medical billing service providing end-to-end revenue cycle management services will take every available step to fight for the reimbursement of all our clients.  Radiologists, in particular, have no presence in the ordering physicians decision to order advanced imaging services.  The hospital may step in with this, but either way the affect will be detrimental.

The policy will be rolled out to all but one of the 14 states where Anthem does business by March 2018, ultimately affecting 4.5 million members, according to an Anthem spokeswoman. New Hampshire is the exception.

In the other states, patients will have to go to a free-standing imaging center instead of a hospital for some services.

Anthem said the policy will help keep premiums low and gives patients an opportunity to save hundreds of dollars, especially those members enrolled in high-deductible health plans. 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.

The imaging site-of-care policy follows Anthem’s announcement earlier this year that it will no longer pay for emergency room visits in non-emergency situations. That policy, meant to push patients to get care from primary-care doctors or in retail clinics, is effective in at least three states.

While healthcare industry experts say Anthem’s policy is new and exclusive, it also adds to the bureaucracy associated with the healthcare industry as a whole, something the patients will “pay for” in the end.

Anthem is partnering with AIM Specialty Health, a radiology specific management firm with a goal to implement its site-of-care program.

If you are concerned with how this will affect your practice, or your group, please consider allowing Medical Business Office, Inc. to take over all your worries by providing professional medical billing services with end-to-end revenue cycle management services.  Our office is prepared to fight to the end on your behalf.  Remember, if YOU don’t get paid, MBO doesn’t get paid.  We have good reason to join forces with your office.  Call today at 573.634.7155.