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Anthem policy drives outpatient imaging services out of hospital-owned facilities; will other services follow?

A new Anthem policy that took effect July 1 for local plan members in Indiana, Kentucky, Missouri and Wisconsin drives patients who need outpatient imaging services to freestanding facilities. The policy went into effect for members covered in Ohio on Sept. 1.

 Under the new policy, AIM Specialty Health began reviewing the requested level of care for imaging services; patients admitted to the hospital will be covered for outpatient imaging services at hospital-owned facilities, but all other requests for outpatient imaging will be steered toward freestanding centers. Members who undergo outpatient imaging services at hospital-owned facilities deemed medically unnecessary in the setting will be responsible for the entire bill.

Pediatric patients are included in the new policy and will be driven to freestanding imaging centers that meet criteria for pediatric patients if they are available; if not, pediatric patients will be able to undergo outpatient imaging at hospital-owned facilities.

Outpatient imaging services at freestanding facilities are typically less expensive than the same services at hospital-based facilities, meaning members that pay a percentage of the overall cost out-of-pocket could see reduced costs; members with facility copay plans likely won't see a reduction in their out-of-pocket expenses.

Anthem Blue Cross Blue Shield of Missouri Senior Clinical Director Jay Moore, MD, told the St. Louis Dispatch the insurer saw cost differential of around 500 percent between the hospital-owned and freestanding facilities.The new policy could decrease spending on outpatient imaging services.

In the past year, Anthem stopped paying for "unnecessary" emergency room visits, including those for the common cold or sore throat, in select states.. Instead, the insurer instructed customers to seek care in lower cost settings such as urgent care facilities. The St. Louis Dispatch hinted the payer could take further steps to rein in costs, which could include driving care such as surgery to the most cost-effective setting.

Other payers may be moving in that direction as well; RAC Monitor reports a memo from Humana notified providers earlier this year that 145 surgeries on the inpatient-only list could now be performed in the ASC for Humana Medicare Advantage patients, including total knee and hip replacements, cervical spine fusion and carotid artery stenting.

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Illinois health system opens new surgery center—4 insights

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