Health insurance giant Anthem plans to stop automatically paying for hospital-based outpatient CT and MRI exams for its members, shifting instead to what it calls a "medical necessity review" of these exams designed to move studies to freestanding centers.
The company is partnering with AIM Specialty Health (AIM), a benefits management firm based in Deerfield, IL, to implement this new review process. As of July 1, Anthem enacted the policy for members in Indiana, Kentucky, Missouri, and Wisconsin; as of September 1, the policy will begin for members in Ohio, the company said.
After September 1, when practitioners order a CT or MRI exam at a hospital-based outpatient facility, they will receive a list of alternate freestanding imaging centers. If providers still select the hospital-based facility, they will need to indicate a reason why the location is medically necessary, Anthem said. AIM will then review the request.
"AIM will review the imaging service request both for clinical appropriateness and the level of care against health plan clinical criteria," Anthem wrote in a May letter to its providers. "If the service is medically necessary but the outpatient facility setting is not, a medical necessity denial would be issued for the service. The physician will be given a list of alternative freestanding imaging centers that are clinically appropriate."
The company is enacting the new policy in part to reduce the per capita cost of healthcare, it said.
