UnitedHealthcare (UHC)*, the largest commercial insurance company in the United States, announced a new site-of-care policy for MR and CT procedures conducted in hospital outpatient departments (HOPD). Effective January 1, 2019, the payer will conduct site-of-care reviews for these exams during the prior authorization process. UHC explained this policy furthers their commitment to the Triple Aim of reducing health care prices, improving services, and generating quality outcomes.
Click to jump ahead for answers to top questions about UHC's policy
The bigger picture: Implications for hospital-based imaging
This isn't the first time hospital-based imaging has been targeted by commercial steerage. As the number of patients on high-deductible health plans reaches critical mass, insurers and employers have not seen sufficient benefits from patient-led price shopping. Their response seems to be doubling down on steerage, effectively positioning themselves as the "shopper."
UHC's announcement comes on the heels of Anthem implementing a similar policy last year. However, UHC takes the pressure on hospital imaging departments to a new level. UHC holds 12.9% of national health insurance market share, more than double Anthem's 6.15%. And with the largest insurer adopting Anthem's controversial policy, it is likely that other health plans will follow suit. While imaging volumes overall are continuing to move outpatient, these insurer initiatives mean that, absent an effective response from health system leaders, they may move away from the hospital-owned setting.
How imaging leaders should respond
Imaging leaders must refine their outpatient strategy to avoid loss of market share in a high-growth area. Consider these three steps:
Step One: Understand potential volume impact
First, understand how UHC's and Anthem's policies affect your market. Volume shifts will depend on your location, payer mix, patient price sensitivity, and outpatient imaging footprint. Use our five step equation to size the impact on your hospital.
Access the Outpatient Imaging Market Estimator tool here.
Step Two: Implement short-term strategies to protect market share
Hospital responses to this trend should focus on retaining patients. Consider these two short-term tactics:
- Proactively steer impacted patients to lower-priced in-network sites. Schedule Anthem and UHC patients at these facilities to retain patients at risk of being steered to lower priced competitors.
- Consider bargaining with payers. Begin conversations about renegotiating contracts so that payers can meet savings goals without steering away hospital volume. For example, explore lowering hospital Anthem or UHC prices for impacted imaging services for at least one facility.
Refine your imaging pricing strategy with these resources
Step Three: Consider building out or expanding freestanding imaging footprint
In light of the sea change driven by Medicare, commercial payers, and patient demand, many imaging providers are seriously considering the option of offering lower-priced imaging in their market. Review the questions on page 20 of Growing Outpatient Imagingfor best practices on building and optimizing freestanding imaging.
Top questions about UnitedHealthcare's policy
Beginning January 1, 2019, UHC will conduct site of care reviews during the prior authorization process for MRs and CTs ordered for the hospital outpatient setting. Below we answered the most pressing questions. Review more information on UHC's website.
Who is impacted?
The policy impacts the following UHC commercial and exchange health benefit plans:
- Neighborhood Health Partnership; and
- UnitedHealthcare of the River Valley.
The below table outlines the impacted care settings and states.
We interpret HOPDs as those located both on and off the hospital campus. In other words, HOPDs are all sites billing at the higher hospital rate.
What procedures are impacted?
This policy impacts certain MRI, MRA, and CT imaging procedures performed in a HOPD. UHC selected procedures that are both clinically appropriate to perform in a freestanding or office facility and have variable prices between hospital outpatient and freestanding settings. Review page two of the UHC FAQ for exact procedure codes which spans most services within the modalities.
What if there isn't a nearby freestanding facility?
If there isn't a freestanding facility in the patient's market, the imaging exam will be authorized in the HOPD setting. However, UHC did not specify what constitutes too long a distance for the patient to travel to a freestanding facility. The insurance company refers providers to their list of participating freestanding imaging centers to understand availability within a selected market.
Advisory Board is a subsidiary of UnitedHealth Group, the parent company of UnitedHealthcare. All Advisory Board research, expert perspectives, and recommendations remain independent.
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