How to Shop for a Radiology Procedure
By Jordan Epstein
I remember the last time I bought a car. I knew I wanted a convertible, so I went from dealer to dealer test driving for important features like trunk space and speed of transformation (yes, I looked at the Camaro first) before settling on a model, and then I checked Kelley Blue Book, called a few dealers, and settled quickly on a fair price. (For the record I chose a 2014 Ford Mustang. It’s awesome.)
Healthcare is nothing like that. For obvious reasons, test driving isn’t the best idea, and without transparency, it’s hard to identify what model of healthcare providers you want, and even harder to find information about the features affecting their price and quality.
So I thought I’d write you this step-by-step guide through the labyrinth of this one small corner of the healthcare industry to help you find the care that’s right for you. Here we go.
1. Find your CPT code
So your doctor says you need imaging. Don’t panic–calmly look at the order form the nice lady at the front desk has handed you. It should say something like “Requisition for Imaging”, and have a description of procedures requested, often with check boxes down the side with the one or two marked for your procedure. What you’re looking for is your procedure’s current procedural terminology (CPT) code. These are specific numbers and letters that identify each procedure. CPT codes are standardized so that no matter which insurance and healthcare provider you use, you have the same CPT code. If you can’t find it on the form, you can easily learn the CPT code for your procedure by asking your doctor, looking it up online, or using an app like Stroll. Note that location on the body and whether or not the procedure comes with ‘contrast’ all affect the code.
2. Know your insurance network
If you don’t have insurance, then you can go to any provider and pay the cash rate (but be sure you ask for their discount cash rate first—we’ll have another article out on this topic soon). But if you’re insured, you’ll need to find out whether a provider you’re considering is in-network or out-of-network. Your insurance will pay a larger percentage of in-network care than it will for out-of-network care, and sometimes out-of-network care won’t be covered at all. So if you can, you should choose an in-network provider. Be sure that both the facility (which could be a hospital or an independent center) as well as the radiologist (one of the facility’s doctors who is an expert in medical imaging) are in-network for your insurance plan. You can call the provider to check that both the facility and the radiologist are in-network. Be sure to use the word “in-network” and not “covered,” because some facilities can be deliberately misleading and say that you are “covered” when they are out-of-network, because your plan includes both in-network and out-of-network benefit. If a facility can’t or won’t answer the question of whether they and their radiologists are in-network for you, go somewhere else.
Some of you, especially those insured directly by hospitals or academic medical centers, might have a multi-tiered plan. Multi-tiered plans usually have ‘Gold’ or ‘Preferred’ in-network providers, which often have little to no cost-sharing for you as a patient. It’s important to know and seek out those top-tier providers–call your insurance company or your company’s health administrator.
If you’re based on the exchange, you might see a benefit that distinguishes between ‘freestanding’ and ‘outpatient hospital’ centers. Unfortunately, neither your insurance, that center, or anyone else actually knows what type of center your insurance will definitively assign to which category, but you can take a guess and google the imaging center. If it seems to be affiliated with a hospital or medical group that sounds familiar and does more than just imaging, it’s probably not freestanding.
3. Understand your radiology benefit
If you’re insured, your imaging benefits will determine how much you end up paying out-of-pocket. Some imaging benefits require just a copay, or a flat rate regardless of what the insurance company ends up paying. Others require a coinsurance, in which case you have to pay the full amount of the final price up to your deductible, at which point you and your insurance split the difference based on your coinsurance. Deductibles can vary from nothing to several thousand dollars, and often for high-deductible plans, you personally—not your insurance company—will be responsible for paying the full price. You can confirm your current deductible status by calling your insurance company or logging onto their website. Check on your imaging benefits by looking for a document called “Summary of Benefits” and searching for the right benefit for your procedure, usually ‘MRI/CT’, ‘Mammogram’, ‘General Diagnostic’, or ‘Xray’.
4. Estimate cost of care
When you’ve found some providers that seem promising, you have a few ways to research cost. One is to call the provider and ask about their cash price for your CPT code. Be aware that while providers may be able to tell you the cash price without insurance, providers negotiate prices with each of their partner insurance companies, and unfortunately they don’t usually share these negotiated prices with patients. You can also do some research on your insurance company’s website, but even within one insurer, individual people’s plans differ, so you might not be able to factor in your own plan’s radiology benefit. Because providers and insurance companies can be difficult to contact and lacking in transparency, Stroll can give you the information you need to find the best value care. Stroll offers price quotes for each facility in your area based on your up-to-date insurance information, making cost comparison simple.
No matter your insurance, hospitals are usually much more expensive than independent imaging centers, potentially several times more expensive. By charging more for outpatient procedures, hospitals can offset some of their other high costs. Independent imaging centers tend to be much smaller, with lower overhead, so they can offer patients lower prices. Especially if you’re not currently hospitalized, you can find equally high-quality but much more affordable care by choosing an independent facility instead of a hospital.
5. Making the switch
If your doctor just handed you a list of providers and left you to your own devices to find an imaging center, you can just go ahead and the center and ask for an appointment. For most of us, though, your doctor will have referred you to a specific provider. Now you face a quandary. There are many reasonable reasons why your doctor might prefer one location over another, especially when it comes to interoperability (the fancy health care word for the ability of your doctor to be able to easily the results of another’s) and preference for equipment, image type, and radiologist. You can read more about what matters in quality in radiology, but the point is that you run the risk of ticking off your doctor if you simply make the switch without asking. So I’d recommend calling your doctor’s office, and if you don’t hear a reason that makes you compelled to continue with the center your doctor referred you to, go ahead and make the call.
If you’re paying with a typical commercial insurance, it’s likely that the center will also need to get “prior authorization” from your insurance company. Prior authorization confirms that your insurance company is aware of where you’re receiving care and believes the care to be medically necessary. Note that you only need prior authorization if you’re insured through an insurance company. If you’re paying independently or with standard Medicare, you don’t need prior authorization. Make sure that you tell your new imaging center your doctor’s name and phone number, as it’s likely they’ll need to contact your doctor to get your health records.
6. Getting the test
In all cases, be sure to bring your photo ID and original doctor’s order, and insurance card if you have it. Make sure that the center has your doctor’s contact information and that they’ll send your doctor the results of the radiologist read or films if necessary. Unless otherwise instructed by your doctor to pick up the actual film copies of your images, don’t leave the imaging center without a DVD copy of your images.
7. The payoff
At the end of the day, it is possible to find peace of mind and high quality, affordable healthcare. Even if your doctor has made a referral, you can still learn more about your options, talk with your doctor about alternatives, and find the best value center for you–just as you would with a new convertible. Now that you’ve read about shopping for an imaging center, you’re ready to learn what to expect from an MRI. Look forward to reading your thoughts in the comments!
Stroll Health is dedicated to helping you reach quality, in-network, low cost care.