Improving Member Access and Affordability Through Smarter Sites of Care

Despite typically being less affordable, 60% of imaging is still performed in the hospital setting, often with no clinical reason to have the imaging performed at that site of care. The reasons are twofold: First, providers typically refer within their own health systems. At the same time, members often don’t know to ask for other available options, and they’re not aware that local non-hospital sites may have the same capabilities – with lower out-of-pocket costs.  

Helping members manage out-of-pocket expenditures is particularly important because those costs nearly doubled for imaging between 2000 and 2019. 

Getting members to a quality, cost-effective, convenient site of care 

Getting members to a high-quality, cost-effective, and convenient site of care for diagnostic testing makes health care more affordable and accessible.  

 “SmartChoice is an educational initiative from EviCore by Evernorth^® that empowers members to choose the diagnostic testing location that suits their needs. The SmartChoice team reaches members over the phone and/or by text typically within one hour of approval for an MRI,  a CT, or a Positron Emission Tomography (PET) scan, which is faster than the member would normally learn of their approval,” said Chad Kersting, EviCore’s Director of Growth Strategy.  

In that interaction, the SmartChoice team acts as a concierge to the member, providing information including the availability of same-quality facilities and the cost of services at those facilities, as well as appointment coordination. The SmartChoice team also helps the member find the most convenient facility locations (e.g., near work, home, or school), and share which sites are in- or out-of-network.  

Once the appointment is scheduled, the SmartChoice team sends reminders to ensure members follow through with their appointment, which helps ensure they get the care they need.  

 “The average cost savings per case is $1,300 when EviCore can help a member choose a more affordable facility through SmartChoice. That savings can be incredibly valuable to people,” added Kersting. 

Members themselves have directly confirmed that sentiment. 

“Words cannot describe the level of support I received from Meg this afternoon (name changed for privacy),” shared one individual who engaged through SmartChoice. “Meg was very kind and patient; she helped me save thousands of dollars and managed to help schedule my appointment earlier than I anticipated! My situation was so much better because of her.”  

EviCore can also conduct medical necessity reviews to ensure the appropriateness of a particular site of care by applying evidence-based clinical guidelines. EviCore offers this service through our Site of Care program. Medical necessity reviews require a medical reason if a hospital or other high-acuity setting is requested for imaging services. If a provider selects a hospital or other higher acuity setting for imaging services, the medical necessity review requires a clinical reason that the higher acuity location is better for the person. A dedicated team is in place to help support providers navigate these reviews.  

The Site of Care program can also integrate SmartChoice’s dedicated concierge guidance and scheduling for members, as well as offer facility options outside the radius of the Site of Care program for added member choice. 

Savings through EviCore’s SmartChoice and Site of Care programs total about $130 million annually. Health plans and employer groups can use these savings to manage premium costs and offer more services to members. 

Member engagement as a quality driver and member satisfaction tool 

Personalized interactions and positive, supportive patient care experiences can also help drive quality and member satisfaction. This is important because delivering a great member experience can help improve Centers for Medicare & Medicaid Services (CMS) Star Ratings and Healthcare Effectiveness Data and Information Set (HEDIS) performance. In fact, for the 2025 measurement year, one-third of Star Ratings will be based on member experience. Similarly, for HEDIS, one of the measurable six core “domains of care” includes the “Experience of Care.”  

Direct member engagement also encourages members to adhere to recommendations and processes, which can help with their overall outcomes. For example, if health plans can connect a member to a more affordable, convenient choice for an imaging scan, the member is more likely to get that scan. This in turn leads to a more accurate diagnosis and a more effective treatment plan — all from ensuring a member receives the right care at the right place at the right time.