Rapid brain MRI protocols cut payer costs while patient out-of-pocket spending remains unchanged
Rapid brain MRI protocols appear to help cut payer reimbursement costs while patients’ out-of-pocket spending remains unchanged, according to new research.
Such “fast” or “abbreviated” examinations take less time by leveraging fewer sequences to answer a targeted clinical question. This type of imaging is increasingly being implemented in clinical care, though financing and billing practices have lagged these advances, experts write May 16 in Pediatric Radiology.
Researchers recently aimed to better understand how rapid MRI has impacted imaging economics, pinpointing patients with private insurance who underwent an outpatient brain MRI at Cincinnati Children’s. They found that these advances are mostly benefiting insurers and providers financially, rather than the person being imaged.
“Although rapid brain MRIs reduced payer reimbursement, patient out-of-pocket costs remained unchanged,” Shireen Hayatghaibi, PhD, health services researcher and assistant professor at the University of Cincinnati, and co-authors concluded. “Inconsistent recognition of the limited modifier underscores the need for updated CPT codes and reimbursement policies aligned with evolving imaging practices.”
The study included a total of 147 standard MRIs and another 166 rapid MRIs, with the latter identified using the “52 modifier.” Some providers apply this modifier to indicate a “reduced service” or partial reduction in the MRI exam and a corresponding lower charge and reimbursement. Others often still bill for the full MRI exam, even if it's abbreviated, the authors noted, resulting in a lack of consistency across different health systems.
In the study sample, most MRI exams included patient cost sharing—about 77% for standard scans and 69% for rapid ones. Payer reimbursement differed by exam, with higher payer costs for standard MRI (at an average of $2,760) compared to rapid exams ($1,986). Among exams with cost sharing, the average total out-of-pocket costs were similar between exam types at about $1,206 for standard MRIs and $1,285 for rapid imaging. In about 43% of abbreviated MRIs, the payer did not recognize the limited modifier, the study found.
“This inconsistency undermines the intended purpose of the limited modifier, ultimately resulting in patients incurring similar out-of-pocket costs for examination coded as reduced imaging services,” the authors wrote. “This suggests a need for coding standards, such as the creation of a distinct CPT code that reflects changing imaging practices. As rapid MRI continues to expand in clinical use, policy and reimbursement frameworks must also adapt.”
Read more, including potential study limitations, in Pediatric Radiology.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.