Cigna becomes third major payer limit MRIs, CT scans at private hospitals

Soon after Cigna Corp. waived prior authorization requirements plus eased coverage rules to ensure sufferers could receive needed care throughout the coronavirus pandemic, the health insurer stiffened restrictions in other areas.

In August, the nation’s 4th largest insurer by membership grew to become the third major payer to restrict insurance for most advanced imaging, such as MRIs and CT scans, when carried out in a hospital-based department or service, except in limited circumstances.

The policy pertains to Cigna’s members within self-funded employer plans, fully covered commercial members, and Cigna’s personal employees and their dependents. These groups make up most of Cigna’s seventeen million members. The company intends in order to roll out the policy to person and family plan members within January.

Cigna’s policy is similar to those put in place simply by Anthem in 2017 and UnitedHealthcare last year. Anthem’s questionable rule—the first of its kind—drew ire and litigation from hospitals . Providers argued that the policies vulnerable to sap a large source of income while eliminating patient choice plus interfering with the doctor-patient relationship.

Like the insurers prior to it, Cigna said its brand new rules are meant to direct patients far from expensive hospitals toward lower-cost services, such as free-standing imaging centers or even office settings. What makes Cigna’s plan stand out is it was implemented within the throes of a pandemic, when private hospitals are dealing with lower-than-normal patient quantities and resulting financial losses.

“Policies such as these limit patient access to care without consider to the quality or coordination associated with care, ” said Molly Jones, vice president for coverage plus state issues forum at the United states Hospital Association. “It is particularly troubling to see these kinds of unilateral steps to decline patient access to care during a worldwide pandemic. ”

Health insurers have long determined what to cover based on whether they believe a service is medically necessary for the patient. Only more recently have they started dictating where that patient need to get that service, as they attempt to tamp down claim costs.

“The goal from the policy is to provide coverage for the customers to get the right care in the right place and the right time, inch a Cigna spokeswoman said within an email. “That means helping to immediate them to a freestanding radiology middle or other office-based settings if you find not a clinical reason for services to become performed at a more costly hospital environment. ”

It can true that the cost of an image resolution service varies drastically by in which a patient receives it. The cost of a good abdominal MRI costs $1, 751 at a hospital and $680 in a freestanding imaging center, according to health care price transparency company Amino . With nearly 46% people with private insurance in the high-deductible plan, patients could be over the hook for a large portion of that will cost. Freestanding imaging centers are usually cheaper because they provide one provider and have less overhead.

A spokeswoman for Many Health Insurance Plans, the health insurance sector’s lobbying group, said in an e-mailed statement that “promoting lower-cost configurations for services that provide the same degree of high-quality, effective care is one of the methods we work for lower premiums plus out-of-pocket costs for you. ”

But critics believe the insurer site-of-care policies concentrate narrowly on cost and overlook the quality of an imaging center. Analysis shows that in healthcare, higher expenses don’t correlate with better quality.

“It’s a solely cost-based policy, which is why we have a problem with it, ” said Kathryn Keysor, senior director of economics plus health policy at the American University of Radiology. “If they could reveal that quality was better with certain places, or if they a minimum of took quality into account—but they will not. ”

Presently, there is no data available to compare the standard of imaging centers, so it’s hard to understand how patients could be affected by the plan, said Leah Binder, CEO associated with Leapfrog Group, a not-for-profit centered on the quality and safety of health care.

“What I believe health plans should be doing can be developing quality measures on image resolution. We don’t have good ways to gauge the quality, and until we do this, this method could very well be pennywise and lb foolish—or not, we just how to start, ” she said.

A poor-quality imaging middle could lead to mistaken diagnoses, which could lead to mistaken treatments and eventually reparative remedies, she said, “which is much more expensive than any differential in between imaging in a hospital and image resolution in outpatient. ”

Research suggests imaging facilities aren’t created equally. One 2016 study in The Spine Journal found wide variation amongst 10 imaging centers’ MRI examination findings of a 63-year-old woman along with low back pain. The ten exams produced 49 different results, from disc bulges to disk generation to stenosis. None of the particular reported findings were unanimously documented in all 10 examinations. Researchers furthermore discovered “an alarmingly high number associated with interpretive errors. ”

Other critics argued the particular policy takes away patient choice undercuts a physician’s judgment.

“They should give the home owners patient and the physician a chance to possess a dialogue instead of these one-way guidelines, ” said Rick Gundling, mature vice president of Healthcare Economic Management Association.

Dr . Marc Succi, an emergency radiologist and director of the MESH Incubator, a technology incubator at Ma General Hospital, said policies that will push patients to providers that will aren’t integrated with the hospital might make it difficult for a doctor to get a complete picture of a patient’s health.

“We get Compact disks missing half the images through all these outpatient centers or various other hospitals that are not part of our bodies, ” he said. “The technologies is not quite there… Asking individuals to go get their CDs from outpatient centers is not efficient and not great continuity of care. ”

Succi also stated patients sometimes have complications throughout imaging, such as a reaction to contrast, the dye used in during some MRIs. In those cases, it helps to stay a hospital setting where assist is 30 seconds away, he or she said.

Cigna said it would continue to allow providers to be performed at a hospital if a patient’s condition warrants it. It might consider high-tech imaging in a hospital-based facility to be medical necessary every time a patient has a known allergy in order to contrast that is going to be used, or once the patient is under 10 years aged or is pregnant and demands obstetrical observation or perinatology providers.

The insurance provider also made exceptions for whenever imaging is related to a transplant, or even when there are no appropriate option sites available for the patient to receive image resolution. It would cover pre-operative imaging which is integral to a surgery or various other procedure being performed at a medical center, or if imaging outside of the hospital is expected to adversely impact or delay care, for instance.

Beyond MRIs plus CT scans, the policy furthermore applies to magnetic resonance angiography plus computed tomography angiography. It does not affect x-rays or mammography.

The policy could worsen the financial woes of private hospitals, which struggled with lower-than-normal affected person visits during the earlier months of the pandemic when companies postponed non-urgent procedures. Hospital radiology departments saw a decrease in the amount of patients receiving MRIs, CT tests and other imaging services. Historically, radiology has been a moneymaker for hospitals.

“It’s just one harder thing, ” Gundling said. “Anything that puts a block ahead of the patient’s and hospital’s relationship, it might be never a good thing for the patient or maybe the hospital. ”

According to a study by scientists at New York-based Northwell Health, total imaging amounts at the health system decreased 28% over a 7-week period during the outbreak, compared with the same period in 2019. At its worst, volumes dropped 88% in the outpatient setting, as the number of MRIs delivered fell just as much as 74%.

Experts from Mass General similarly discovered that average every week imaging volume declined 54% in the main hospital campus and 64% at affiliated imaging centers in between late March and late Might, compared with before the pandemic. According to Succi, one of the study’s authors, finances possess recovered, but that doesn’t necessarily mean budget have.

There is absolutely no data showing how insurers’ image resolution site-of-care policies have affected medical center finances or patient care. Keysor said the American College associated with Radiology hasn’t received calls through hospitals about their volumes losing significantly due to these policies.

But Brian Tabor, president of the Indiana Hospital Organization, said Anthem’s policy, which has been essentially for a few years in the state, has created a few problems.

“Anthem’s policy created disruptions in booking, often resulting in repeat or terminated visits or procedures, ” this individual said in an email. “A terminated operating room visit, for example , not just delays care for that patient it also limits access for another patient that could have been scheduled. In addition , patients are occasionally sent to low-quality imaging which offers problems for the diagnosing physician plus their patients. ”