Why Imaging Is 6-11% of Plan Spend and How Direct Contracting Fixes It, With Dr. Cristin Dickerson

Imaging costs 6 to 11% of total plan sponsor spend — and that figure requires aggregating CPT codes, contrast charges, professional services, and facility fees, many of which are split across different code categories in ways that make the true total hard to see. The same MRI that costs $5,000 at a hospital system might cost $300 to $500 at a freestanding imaging center of equivalent quality. And prior authorization for imaging, per a study by the American College of Radiology, does not reduce the number of scans performed — it only delays care.

In this episode, Stacey Richter speaks with Dr. Cristin Dickerson, MD, founding partner of Green Imaging, an $18 million physician-led radiology network, about why direct contracting for imaging is one of the highest-leverage moves a plan sponsor can make — and how to actually do it, including when to go around the TPA entirely.

WHAT YOU'LL LEARN
✅ How hospital revenue codes allow imaging claims to bypass standard CPT-based claims adjudication — the Osceola County school district case found one CT scan billed at over $50,000 using hospital revenue codes rather than CPT codes, escaping standard review entirely

✅ Why 62% of Texans are delaying or forgoing care because they can't afford it — and how direct contracting with zero member cost-sharing can solve an access problem while the employer still saves money, as the City of Plano health plan discovered

✅ Why prior authorization for imaging delays care without reducing utilization, per the American College of Radiology — and how radiologist-specific protocols (such as clarifying whether contrast is truly needed, which eliminates unnecessary contrast in roughly 30% of chest CT orders) do more to control appropriate use than prior auth

✅ Why TPAs often cannot or will not facilitate direct imaging contracts — because of carrier contract clauses, competing internal vendors, or referral fee arrangements — and how approximately 80% of Green Imaging's larger employer clients simply go around the TPA and contract directly

✅ How employers can execute a direct imaging contract without TPA involvement: under HIPAA's omnibus rule, employers can withhold PHI from carrier network partners and pay cash, Green Imaging sends a single invoice with all data needed for stop-loss compliance, and there is no repricing or prior auth complexity

✅ Why the "down the hall" referral habit is weakening as patient bills get larger — doctors often cannot estimate what imaging costs at their affiliated hospital, and patients are increasingly aware of the risk of an unexpectedly large bill

WHY THIS MATTERS
When a plan sponsor pays for imaging through a traditional claims process, they are paying whatever the system decides — which can include misapplied codes, facility fees, contrast charges in separate buckets, and RBP fees that sometimes exceed what the provider actually received. Direct contracting strips all of that away. The price is set in advance, the member pays nothing, the provider gets paid quickly without collections overhead, and the employer saves money. The model works. The barriers are real but navigable.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP486

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00:00 Introduction and Episode Overview
00:31 The Case for Direct Contracting in Imaging
01:43 Real-World Examples and Challenges
04:47 The Importance of Data and Transparency
08:49 Interview with Dr. Kristen Dickerson
12:39 Barriers to Direct Contracting
24:05 Overcoming Barriers and Final Thoughts
33:22 Conclusion and Contact Information