USA – UnitedHealthcare (UHC) is rolling out a program in which imaging providers are graded based on established quality and efficiency metrics, with patients receiving tiered cost benefits for visiting such facilities.
Hospitals and freestanding imaging centers with UHC contracts must complete an online questionnaire demonstrating that their services meet certain criteria in order to become a Designated Diagnostic Provider.
When the program goes into effect on July 1, plan members will have lower out-of-pocket costs for imaging at these facilities.
According to UnitedHealthcare, the new benefit’s local availability is subject to state regulatory approval.
Several exclusions are listed, including the state of Hawaii, Medicare and Medicaid plans, and imaging services performed on an admitted inpatient, in an emergency room, or at a specialty or primary care provider office.
Patients seeking major radiology services, such as magnetic resonance imaging, CT, MR angiography, PET, or other nuclear exams, will now be required to visit top-tiered providers in order to incur the lowest out-of-pocket cost.
UHC launched a similar program for diagnostic lab services last year, and it claims that its imaging program is intended to protect patients from costly radiology.
“Including these standards of care into our Designated Diagnostic Provider benefit design is an important step to improving the member experience and making healthcare more affordable by addressing the high cost of certain services that can be performed at a lower cost by different providers,” UHC said on its website.
All providers are evaluated using the same quality measures, which include accreditation status, timeliness of care and test results, and electronic image submission. Meanwhile, all efficiency metrics include the same cost target.
Providers who do not meet the tier one requirements for a Designated Diagnostic Provider will be placed in the second tier.
These facilities will continue to be in-network, but patients will not receive the same benefits, including higher out-of-pocket costs.
Small group commercial plan members who are fully insured had the new benefit added to their insurance on January 1, while large group beneficiaries will join them on July 1.
Members and referring physicians will be able to identify and use Designated Diagnostic Providers on the same summer date in five months, according to the insurer.
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