By Scott Gartenman, JD ISMA Director of Health Policy

Indiana physicians are facing new restrictions from the state’s largest insurer, Anthem, which may interfere with their ability to provide appropriate patient care.

Anthem has recently implemented a new outpatient imaging policy limiting the circumstances in which certain tests will be reimbursed. Anthem will no longer pay for MRI and CT imaging performed for outpatient care when rendered in a hospital setting. The policy is being promoted as a cost-saver for patients, based on data suggesting freestanding imaging centers provide services at a far lower cost than hospitals with the same technology.

The change will impact hospital-employed physicians more than others, as they will have an obligation to send their patients outside of the hospital system for imaging services. Failing to do so would lead to significant increased costs being passed on to their patients.

Physicians should be aware of these restrictions when ordering tests and help guide patients to imaging centers or refer them to Anthem for followup. This aligns with a recent change in Indiana law requiring physicians to state on all orders and referrals that patients should verify with their insurance carriers whether the service is covered and where it can be rendered. However, Anthem’s refusal to pay for these imaging services in a hospital setting will create difficulties for patients who lack access to a nearby freestanding imaging center.

ER services scrutinized
A second new Anthem policy, which affects payment for services rendered in an emergency room, is scheduled to take effect next year. The new policy would shift the responsibility for payment to patients when Anthem deems a visit to the ER occurred and the patient presented at the ER with nonemergent conditions. ISMA and other stakeholders have already sent Anthem a joint letter opposing the implementation of this policy in Indiana.

Anthem has given little detail as to how it will decide whether a visit was for emergent reasons. The “prudent layperson” standard has long been the accepted ER review standard for approving or denying payment. Based on the experience of states where the policy already has been implemented, the Anthem review seems to be a second bite at the apple: The insurer looks at the conditions charted after a full visit has concluded and uses an algorithm to review diagnoses. Questions as to the legality of this policy remain, and ISMA and the AMA are engaged in an effort to fight this change.

These policies represent a new trend among insurers, with more changes sure to come as cost-control measures grow. These shifts from established patient care norms have the greatest impact on patients, who may receive large, new, surprise bills. The exclusion of hospitals from providing outpatient-imaging services, as well as a move away from the long-held prudent layperson ER standard, create concern for physicians about whether they can provide appropriate patient care.

Stay tuned for updates
In a time when administrative burdens are already high, these new policies add a new layer of requirements unrelated to giving patients the highest-quality care possible. ISMA will continue to monitor these types of policy changes from other insurers and update you as they emerge.