Payor and patient costs for rapid brain MRI: analysis from a single pediatric institution

Abstract Background “Rapid” “Fast” or “Abbreviated” MRI examinations, which leverage fewer sequences to answer a targeted clinical question, are increasingly being explored as clinical tools. Objective The purpose of this study was to evaluate and compare payor costs and patient out-of-pocket costs for brain MRI without contrast compared to a rapid brain MRI among commercially insured patients at a quaternary academic children’s hospital. Materials and methods We performed a retrospective search to identify patients with private insurance who underwent an outpatient brain MRI without contrast (standard MRI) or rapid brain MRI at our quaternary academic children’s hospital. Examinations lacking complete payment information were excluded, and only the first exam per patient was included. All rapid MRIs were included; an equal number of standard MRIs were randomly sampled by month. For rapid MRI examinations, we calculated the frequency of cases in which the payor did not recognize the limited modifier, as indicated by the payor reason codes. For all examinations, we calculated the (1) payor cost (the amount reimbursed for the exam) and (2) the patient’s total out-of-pocket cost, calculated as the sum of the deductible, coinsurance, and co-payment. Descriptive statistics were used and means were compared between groups using Student’s t test. Results Our sample included 147 standard MRIs and 166 rapid MRIs (coded with the 52 modifier). Most examinations included patient cost sharing: 77% (113/147) of standard MRIs and 69% of rapid MRIs (115/166). Payor reimbursement differed ( P <0.001) by examination, with higher payor costs for standard MRI (mean, $2,760; SD, $1,187 vs. mean, $1,986; SD, $198) for rapid MRI. Among examinations with cost sharing, the mean total out-of-pocket costs were similar between examination types (standard, $1,206 vs rapid, $1,285; P =0.55). In 43% (71/166) of rapid MRI examinations, the payor did not recognize the limited modifier. Conclusion Although rapid brain MRIs reduced payor reimbursement, patient out-of-pocket costs remained unchanged. Inconsistent recognition of the limited modifier underscores the need for updated CPT codes and reimbursement policies aligned with evolving imaging practices.