March 07, 2019

Private Insurers Implement Egregious Payment Policies

In its continued effort to track private insurer practices and policies that impact reimbursement of radiology practices, the American College of Radiology (ACR) has become aware of a lawsuit against Anthem, the nation’s second largest health insurer.

The lawsuit by Sovereign Health focuses on payments made by Anthem to rehabilitation patients rather than directly to the hospital and care providers for their services.

Sovereign Health alleges that Anthem’s practice of issuing payments to patients rather than their out-of-network facilities is a retaliatory move against doctors, hospitals and treatment facilities that refuse to accept the insurer’s low in-network rates.

Patients are expected to use the money from Anthem to pay their providers, though collecting funds sent to patients has proven to be very difficult. While the lawsuit is specific to rehabilitation services, there is evidence that Anthem is applying the same practice to surgery patients and other medical specialties.

Separately, UnitedHealthcare, the nation’s largest healthcare insurer., implemented an imaging site-of-service preauthorization program on March 1st.

The policy, first announced last fall and initially scheduled for implementation on January 1, 2019, now denies authorization for MR and CT services in hospital outpatient settings unless the patient qualifies for an exception.

Even then, providers must work through the insurer’s prior authorization process to receive approval for patients under age 10, obstetrical patients, patients with known contrast allergies, patients with chronic diseases that require frequent imaging for management and pre-surgical patients.

UnitedHealthcare may also allow exceptions in cases where there are no geographically accessible alternative sites. Site-of-service reviews will not apply to care providers in Alaska, Connecticut, Iowa, Kentucky, Maine, Utah, Vermont or Wisconsin.

To assess the effects of such private insurer policies, the ACR would like to hear from members whose practices have been impacted by egregious payer policies. Our interest includes but is not limited to payments made directly to patients and site of care preauthorization programs.

Please contact Kathryn Keysor, ACR senior director of economics and health policy, to share your experiences.