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6 Strategies to Address Restrictions on Hospital-Based Diagnostic Imaging Services

Six Strategies To Address Restrictions On Hospital Based Diagnostic Imaging Services Web

Following in the footsteps of Anthem and UnitedHealthcare, Cigna has announced restrictions on providing MRIs and CTs in hospital-based imaging departments, effective January 1, 2021. The new policy, intended to direct more patients to a lower-cost care setting (i.e., from hospital-based to freestanding settings), will affect the majority of Cigna’s 17 million members.

Critics are raising concerns about the policy restricting patient access and increasing the fragmentation of care while simultaneously driving significant financial losses that will impede a health system’s ability to subsidize critical healthcare services that don’t generate the margins necessary to support themselves.

This trend of shifting imaging services to lower-cost settings mirrors trends in surgery and other diagnostic services. Hospitals and health systems need to develop strategies to provide patients with the care they need regardless of setting while remaining financially viable. The recommendations below outline near-term steps organizations can take to mitigate losses and long-term strategies to diversify their imaging portfolios to remain competitive while providing cost-effective care.

Near-Term Steps

  • Assess the potential impact. Quantify the expected financial impact to the hospital-based imaging department based on the percentage of patients (and the associated MRI and CT volumes) affected by this restriction. Conduct sensitivity analyses to anticipate the continued trend in payer site-of-service restrictions.
  • Strengthen prior-authorization processes. Review and update prior-authorization processes to ensure the health system can mitigate losses by avoiding claims that will be denied due to the new restrictions. To maintain volumes, ensure that prior-authorization and patient access staff engage proactively with payers to advocate for patients who require an imaging study at the hospital due to a qualifying medical reason.
  • Prioritize network management activities. Focus on referral management and coordination to reduce care fragmentation and leakage out of the network. Relieving patients of the administrative burden associated with referrals can improve patient retention and ensure that a higher percentage remain in network while helping to offset volume declines associated with site-of-service issues.
  • Engage with payers. Initiate discussions with payers to explore opportunities to reduce the expected negative financial impact to the health system.
    • Negotiate the continued provision of imaging services at the hospital-based imaging department to avoid issues with patient backlogs and the potential limited access to care from diverting volumes to freestanding centers that are not equipped to handle the influx.
    • Negotiate lower reimbursement rates at one or more of the health system’s imaging locations to ensure that patients maintain continuity of care via an in-network option while minimizing volume losses for the health system.

Long-Term Strategies

  • Expand the freestanding imaging footprint. Pursue opportunities to add freestanding imaging assets to the health system’s portfolio through acquisition, partnership (e.g., joint venture), or de novo development.
  • Convert hospital-based imaging departments to independent diagnostic testing facilities (IDTFs). When considering this change, conduct a financial feasibility study to evaluate the impact to the total book of business by shifting from Medicare reimbursement under the Outpatient Prospective Payment System to the Physician Fee Schedule.

For more information or to discuss these recommendations in more detail, please reach out to our radiology experts.