Anthem Now Requiring Pre-approval for Hospital MRIs, CT Scans

The insurer no longer allows outpatient imaging in hospitals. Hospitals may feel the financial loss.

In a bid to cut costs, Anthem is now informing consumers that it must pre-approve any hospital-based MRIs and CT-scans, and that approval won't come easily. 

The insurer's new policy forbids hospital imaging services on an outpatient basis and requires proof that inpatient imaging is medically necessary.

The Anthem change in policy is likely to be a financial blow to hospitals, which have seen outpatient imaging as a profit center in recent years.

Anthem announced recently that outpatient MRIs and CT scans must be performed at lower-priced facilities, citing its commitment to the Institute for Healthcare Improvement (IHI) Triple Aim Initiative, which calls for improving the patient experience, improving population health, and reducing costs.

The insurer says clinical research has shown the safety of imaging services in free-standing facilities, so the additional cost of a hospital setting is unnecessary.

"Anthem's primary concern is to provide access to quality and safe healthcare for our members. We are also committed to reducing overall medical cost where possible when the safety of the member is not put at risk," the company says.

Anthem notes that imaging costs can vary widely without any effect on quality of care, with scans costing as little as $350 and as much as $2,000.

The company also notified providers of the change in policy, explaining that physicians must obtain pre-certification approval for inpatient hospital imaging. Anthem told consumers that it will provide assistance in finding imaging facilities other than hospitals.

The change in policy could reduce a member's out-of-pocket costs, Anthem notes.

"If the member has a benefit plan where he or she pays a percentage of the cost, it is possible that his or her percentage of out-of-pocket cost may be reduced," Anthem says. "This is because the cost to undergo a CT or MRI scan administered in a freestanding imaging facility may be less than what a hospital-based facility would charge. If the member has a facility copay, there may not be a reduction in a member's out of pocket cost."

However, the policy still stands even if using a freestanding facility would not reduce the consumer's out-of-pocket cost, the insurer explains. The approval or denial of the site of service is based only on medical necessity.

In the unlikely event that the physician ignores the policy and the patient receives imaging services in a hospital outpatient setting, the hospital would be responsible for the cost, Anthem says. The patient would not be held responsible unless he or she signed a statement acknowledging the deviation from Anthem policy and agreed to be financially responsible.