Protocol a hurdle for low-cost Smart Choice MRI [Milwaukee Journal Sentinel]

June 29--Smart Choice MRI, with its flat rate of $600 for a scan, has saved employers, health insurers and patients millions of dollars since opening in 2006.

Its price, which includes the physician fee for reading the scan, can be more than $1,000 lower than what hospitals bill for magnetic resonance imaging. And it has drawn attention to how prices vary widely for a common test.

Smart Choice, which contracts with radiologists at Cleveland Clinic to read its scans, did roughly 5,000 MRIs last year at its imaging centers in Milwaukee and Sheboygan.

"We've carved out a big chunk of the local market," said Eric Haderichter, co-owner of Smart Choice MRI.

But he contends that Wheaton Franciscan Healthcare is preventing patients from getting scans at its imaging center in Milwaukee -- a contention that the health system denies.

Sorting out who is right illustrates the complexity of the health care system -- and maybe the potential obstacles that patients can encounter when shopping for the best price for a common test.

That's an incentive that more patients have because they are covered by heath plans with high deductibles, often paired with a health savings account.

Smart Choice MRI contends that Wheaton Franciscan's physicians will not get the required pre-authorization from insurance companies needed for an MRI.

Wheaton Franciscan doesn't deny that.

Its policy is for a health system, imaging center or other health care provider that is providing the service to get the required pre-authorization, said Anne Ballentine, a spokeswoman for the health system.

"We believe it is up to our competitors to do the needed pre-authorization for the services they are going to provide and get paid for," she said.

Getting a health insurer's OK can take 20 minutes -- and in some cases much longer -- and that costs money in staff time.

With the patient's approval, Wheaton Franciscan will provide Smart Choice MRI or any health care provider with the documentation needed for the pre-authorization from a health insurer.

That would strike most people as reasonable.

But Haderichter contends that Smart Choice MRI's contracts with health insurers require that the referring physician handle the pre-authorization. It contends that physicians who work for other health systems do this when a patient wants to get a scan at its imaging center.

Froedtert Health and Columbia St. Mary's Health System confirmed that this is their policy.

In an email, Lisa Froemming, a spokeswoman for Columbia St. Mary's, also said that insurance companies require that the office of the physician ordering the test obtain the pre-authorization for a diagnostic test.

Wheaton Franciscan, in contrast, contends that Smart Choice MRI can do the work needed to get a pre-authorization from a health insurer.

"I am telling you that unequivocally, because we do it all day long," said Coreen Dicus-Johnson, a senior vice president who oversees contracting for the health system.

Wheaton Franciscan handles the pre-authorizations when an independent physician refers a patient for an imaging test.

"It would be one thing if we were thwarting the efforts of Smart Choice MRI, but we are not," Dicus-Johnson said.

Haderichter said that Wheaton Franciscan can handle pre-authorizations for independent doctors who have privileges at Wheaton Franciscan hospitals.

It gets even more confusing -- or maybe comical.

Smart Choice MRI contends that it has encountered the problem only for patients referred by Wheaton Franciscan physicians in Franklin, raising the question whether all of the health system's doctors are aware of its policy.

Health insurers began requiring physicians to get approval for MRIs about two years ago, Haderichter said. Before that, Smart Choice MRI could do the work needed for the pre-authorization.

Health insurers generally require doctors to get approval for tests such as MRIs to help prevent unneeded tests.

Presumably, health insurers could help sort this out. But the health care system doesn't lend itself to simple answers.

Anthem Blue Cross and Blue Shield in Wisconsin said its preference is for the referring physician to handle the pre-authorization, but its policy allows for some flexibility.

Health insurers' policies also vary.

UnitedHealthCare said it requires "prior notification" as opposed to "prior authorization" from the referring physician -- a process that presumably would be less time-consuming.

The outpatient imaging center, such as Smart Choice MRI, then must confirm that a notification number is on file.

But UnitedHealthCare's policy is changing on Monday to require prior authorization for imaging tests.

Keeping track of the different policies -- and the changes in the policies -- is one of the burdens borne by anyone who provides health care services.

Where Smart Choice MRI and Wheaton Franciscan do agree is that patients should have the ability to decide where they want to receive care, provided the doctor, imaging center, lab or hospital is in a health plan's network.

So far, only a few patients have been affected by the dispute between Smart Choice MRI and Wheaton Franciscan.

Steve Kunda, a craftsman who makes cabinets and custom furniture, was one of them.

His doctor, who works for Wheaton Franciscan, ordered an MRI when Kunda was getting migraine headaches more frequently. Kunda scheduled an appointment with Smart Choice MRI.

"It's an MRI. It's going to be the same at either place," he said. "Why would I go someplace else to be charged more money?"

Smart Choice MRI couldn't get the pre-authorization. Instead, Kunda paid cash.

"I just got it done," he said. "That was it."

He probably saved himself from a fair amount of frustration -- and maybe confusion -- in the process.

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