question about Anthem announcement: not paying for outpatient MRI and CT

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Jackson12
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question about Anthem announcement: not paying for outpatient MRI and CT

Post by Jackson12 » Thu Aug 15, 2019 11:54 am

I know that Anthem announced, back in 2018, that their general policy would be to deny payment for outpatient MRI and CT scans performed at hospitals... if patients could save money by going to a freestanding imaging facility.

Now my cousin’s doctor informed him that the radiology services used and preferred by the doctor is cutting all ties with Anthem. The doctor also noted he didn’t believe that many of the available freestanding facilities offered the same advanced imaging available at most of the local hospitals. As a result, our cousin now thinks he should dig deep and simply self pay for the doctor preferred hospital scan

Has anyone else contended with this and found any recourse ( other than self pay) if ones insurance company refuses to pay for imaging and scans that a personal physician considers superior to those offered at freestanding centers ? Written appeals to the insurance company?

Please note: I’m am not disparaging free standing buildings or CT or MRI services in general . I’m only focusing on the issue of restricting patients to specific facilities and imaging services after a physician recommends differently.

Maybe there are complexities here that I’m missing.

deikel
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by deikel » Thu Aug 15, 2019 3:08 pm

A lot does not make sense here.

If the procedure needed is a simple one to do and does not require any special knowledge - say a knee MRI, then one would expect that anyone offering such services has the required quality to do so, it becomes a commodity to do it and is failry cheap (relatively speaking) and ANthem should just declare what the going rate is that they pay in that area and let the customer decide where to go (and let the hospital decide to take the presumable lower payment - or cut ties with Anthem).

If the procedure is special, one would assume only specific facilities can perform it and hence there is no other alternative in a wider traveling range. A stand alone facility claiming to be able to do something and then not providing the quality needed would be rather fraudulent.

If the prescribing doctor considers the work inferior and not clear in its diagnostic value, he would just order another one causing even more cost to the insurance, so that can not be in Anthems interest and should allow a red flag for sub par facilities rather quickly.

I will also say that there are two parts to this, getting the imaging done right (the respective technician running the test/machine) and interpreting the created picture/data correctly - usually the dr on call, these days the doctor located in say India since electrons can be easily moved to cheaper COLA areas. I would argue that the technical quality of the picture can be controlled reasonably well and I will assume that the interpretation is in doubt here. Somewhat assuming the hospital dr is more competent then the free standing clinic one - when realistically both have it outsourced to a third party anyway.

If the prescribing doctor feels strongly about the hospital, maybe finding a specialty scan required for this problem will help the issue, if there is nothing special to it, then free standing will probably do the trick just fine. Also, make sure you get the data in hand and so you could always ask another professional for their opinion and only pay that fee out of pocket vs taking the hit for the whole process.
Everything you read in this post is my personal opinion. If you disagree with this disclaimer, please un-read the text immediately and destroy any copy or remembrance of it.

jacoavlu
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by jacoavlu » Thu Aug 15, 2019 4:22 pm

Radiologist here

Medical imaging is to a degree becoming or at least being thought of as a commodity. I don’t think it should be. Neither should be a joint replacement or a cardiac cath. Sometimes, you and your insurance company get gouged paying higher hospital prices. Sometime, you get exactly what you pay for.

There definitely are two components. The technical quality of the imaging and the expertise of the interpreting physician. Image quality can be a function of magnet strength, brand, age, quality of the protocols and skill of the operating technician. Interpretation quality is pretty self explanatory, the radiologist may be sub specialized with extended training in the necessary area, or might be below average.

The referring physician may have more than one reason for preferring imaging at one location over another. Hopefully your physicians preference is based on a desire for quality care for you.

The outpatient scanner might be an old piece of junk and the radiologist no good at reading. Or the outpatient scanner might be excellent and the radiologist highly skilled. Ditto for the hospital.

Specifics matter.

jacoavlu
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by jacoavlu » Thu Aug 15, 2019 4:39 pm

I’ll also add. Your scan wherever you go is most likely interpreted by a radiologist local to you. Definitely not India. There was a time when some overnight imaging would be interpreted, usually on a prelim basis only (not a final interpretation) by a US radiologist who physically moved overseas (Zurich or Sydney) to cover US nights, without having to work nights. And so the US radiologist could sleep, and be fresh and available to work the next day. This has mostly gone away. It was expensive to live and operate a business over there. Night prelim work is still often outsourced to a “nighthawk” service but those docs live in the US now.

Longdog
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by Longdog » Thu Aug 15, 2019 5:27 pm

jacoavlu wrote:
Thu Aug 15, 2019 4:22 pm
Specifics matter.
They sure do. How would a layperson know enough to make the best decision for him or herself? It seems like every party involved in the transaction has their own angle, so you don’t know who to trust.
Steve

jacoavlu
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by jacoavlu » Thu Aug 15, 2019 9:09 pm

You want imaging on a high field system. Most commonly that’s a 1.5T (Tesla) magnet. There are a few high field open scanner but most open MRI systems are low field and produce a lower quality scan sometimes to a severe degree. So you could inquire about the specific machine that a center uses. There are 3T systems, more often found in hospitals, which can do some exams better and faster but that’s not universal and not often necessary outside of some specialized scans. There are times when a 1.5T scan is often superior to a 3T, for instance cervical spines are usually better on the lower strength because of the regional anatomy has common artifacts that are accentuated in the stronger magnetic field. So step one, make sure it’s a high field scanner.

About radiologist quality. That’s difficult. Your referring doctor usually will have some idea. A specialist often knows who is good and who is not so good. You could ask the center if all exams are read by someone with subspecialty training in the field. Like neuro, or musculoskeletal, or body. Not that that’s a guarantee, but it’s somewhere to start. But a center will usually have a group that reads scans, not just one doc. One might be excellent and another subpar. Sometimes a referring doc will request a specific individual to interpret the exam and in my experience most groups would try to honor the request to keep the referring doc happy.

You can also check if the center is accredited by the ACR. That at least shows that they have gone through some process to ensure they can perform scans of adequate quality.

SandysDad
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by SandysDad » Thu Aug 15, 2019 9:16 pm

Cant the doctor just write the script for the type of scan and equipment needed?

Jack FFR1846
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by Jack FFR1846 » Thu Aug 15, 2019 9:26 pm

Your cousin should call Anthem and give them the situation and ask for a list of approved MRI facilities, then go to one of them. That is.....assuming Anthem knows of operating MRI facilities who are in network. I say this since my insurance has no clue when facilities close, doctors die or practices sell out to others. It's always fun being given the name of a doctor who's been dead for 3 years.
Bogle: Smart Beta is stupid

jacoavlu
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by jacoavlu » Thu Aug 15, 2019 9:35 pm

Type of scan, yes. For instance, “Brain MRI without contrast”

But depending on where the scan is performed, scan and or interpretation quality can vary widely.

The OP noted that a referring physician was skeptical of the quality of the freestanding imaging available in their local area. The concern may or may not be valid.

In a nearby community to me, the one freestanding MRI is of low quality. But they also charge a very low price. Sometimes it’s all the patient can afford and in that case it’s better than nothing. Usually the scans are “good enough”. But not always, and sometimes patients end up getting scans repeated at another higher cost facility.

phxjcc
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by phxjcc » Fri Aug 16, 2019 2:49 am

Ssshhh, this a secret, ok?
Just between us.
The rest of you move on.

Always ask what the cash price is for the MRI.

Same facility, same machine, same tech, same radio.

Insured cost: $1200, $200 deductible.
Insured, but not covered/have not met your annual deductible?
That will be $1200 please, in advance.

Cash price: $350.

This is at the facility my neurologist insists that I use.

Every year, MRI Brain w & w/o contrast.

PS: always do the same for prescriptions.

bltn
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by bltn » Fri Aug 16, 2019 6:21 am

Several years ago my self employed brother in law, right after the beginning of the ACA, was uninsured. Unfortunately, he had his first kidney stone at that time. His family doctor referred him to his local hospital for a CAT scan. 2000 dollars cost. I found out that the free standing clinic in my area charged 200 dollars for uninsured patients for this same procedure, to include the reading fee by the local hospital radiologists. He came to my area to get his CAT scan and ended up getting his stone treatment at our local hospital.
I do believe the prices for xrays at the local free standing clinic are less than the prices at the hospital, even for insured patients. Thus Anthem s policy.

Topic Author
Jackson12
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by Jackson12 » Fri Aug 16, 2019 6:31 pm

SandysDad wrote:
Thu Aug 15, 2019 9:16 pm
Cant the doctor just write the script for the type of scan and equipment needed?
He can write the script but insurance won’t cover it unless it’s at a lower cost facility. They’ll usually. inform patients that coverage is limited. I may not have been clear about that. . If lower cost options exist, the insured is penalized for not using them. Or at least penalized when it comes to coverage, even at a hospital that’s in network.
Years ago, that happened to us but we’ve been lucky since then.
Last edited by Jackson12 on Sat Aug 17, 2019 11:41 am, edited 1 time in total.

sambb
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by sambb » Fri Aug 16, 2019 7:15 pm

They want you to go to the cheapest place. It may not matter, but it might. It depends on many factors. In many countries they dont even order a lot of these scans. Its all economics.

InMyDreams
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by InMyDreams » Fri Aug 16, 2019 7:32 pm

jacoavlu wrote:
Thu Aug 15, 2019 9:09 pm
About radiologist quality. That’s difficult. Your referring doctor usually will have some idea.
Heavens, I'm not even allowed to request a specific radiologist to read my mammo. I can only imagine what would happen if I started inquiring about the qualifications of the radiologist reading my MRI...

jacoavlu
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Re: question about Anthem announcement: not paying for outpatient MRI and CT

Post by jacoavlu » Fri Aug 16, 2019 8:18 pm

InMyDreams wrote:
Fri Aug 16, 2019 7:32 pm
jacoavlu wrote:
Thu Aug 15, 2019 9:09 pm
About radiologist quality. That’s difficult. Your referring doctor usually will have some idea.
Heavens, I'm not even allowed to request a specific radiologist to read my mammo. I can only imagine what would happen if I started inquiring about the qualifications of the radiologist reading my MRI...
Sure you can request it. Tell the tech when you have the imaging done.

They may or may not honor the request. My group does this all the time.

Radiology is of course in large part about medical expertise but it’s also a customer service business. Customers include patients, and referring physicians.

Because the service is somewhat seen as a commodity, I think it’s good practice to try to do excellent work and provide excellent customer service.

But sometimes it doesn’t matter. Because the insurance company just wants the cheapest service.

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