What does Anthem’s New Imaging Diagnostics Policy Mean for Your Practice?

Anthem has announced they will no longer cover outpatient MRI and CT scan services, unless the insurance company deems the imaging procedure to be medically necessary. Instead, patients will be referred to a freestanding imaging center. Anthem, which boasts around 40 million members, just enacted this new policy in Colorado, Nevada, New York, Ohio, and Georgia. Indiana, Kentucky, Mississippi, and Wisconsin implemented the change in July, and New Hampshire is the only state that is exempt.

This new requirement could mean serious financial consequences for healthcare facilities that rely on imaging services to bring in revenue. David Levin, MD, professor and chairman emeritus of the radiology department at Jefferson Medical College and Thomas Jefferson University Hospital, believes that this change could severely impact the referral process. He told Radiology Business, “There’s no doubt that hospital-based radiologists also will be hurt, and I think they and the ACR should strongly protest this to Anthem.”

Anthem considers this move to be a savings strategy for patients, and the program will identify what imaging tests are medically necessary and which are not required. The change follows suit with the Centers for Medicare and Medicaid’s recent decision to reduce spending for the prospective payment system by around $500 million.

Anthem has made other bold decisions when it comes to coverage. Earlier this year, they decided to stop paying for emergency room visits for non-emergency cases in Indiana, Kentucky, Georgia, and Missouri. Some critics called the policy risky, as it could encourage incorrect self-diagnosis.

Many healthcare professionals are frustrated by this new policy. “All it does is add dramatically to the bureaucracy of medicine instead of daring to find a more subtle and more flexible mechanism" managing director of the Value Institute for Health and Care at the University of Texas Dell Medical School, Scott Wallace, JD, MBA, told Modern Healthcare.