Search

Affordability of care is a major concern for many in the United States. Part of the affordability of care issue is unanticipated medical bills. A 2018 poll found that unexpected medical costs were the public's greatest affordability concern, ahead of prescription drug costs and even food or rent or mortgage. An important cause of unexpected medical bills is the surprise insurance network gap. The term "surprise billing" is commonly used to describe this problem of unanticipated out-of-network (OON) care, though this is a misnomer because it is actually a "surprise insurance gap." This gap can have significant consequences for patients and families. Hospital-based specialties like radiology have been implicated in the issue. Part of solving this problem includes determining an appropriate reimbursement for physicians who provide unanticipated OON care to patients. The two most commonly proposed methods to determine insurance company reimbursement to providers for OON services are use of a benchmark value and alternative dispute resolution. There is risk in trying to "price set" with a benchmark value. Establishing a predetermined value for services to mitigate against unexpected bills could have unintended and significant consequences, including disrupting good-faith negotiations between insurance companies and providers and impacting access to care. The data indicate that an alternative dispute resolution process can protect patients, lower the frequency of unexpected OON bills, and reduce costs., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Medicare payments to individual physicians are released annually by the CMS. The purpose of this study is to analyze trends in Medicare reimbursement and work relative value unit (wRVU) production to radiation oncologists., Materials and Methods: The Medicare Physician Supplier and Other Provider Public Use File and the CMS Physician Fee Schedule Relative Value Files (to calculate wRVUs) for the calendar years 2012 to 2015 were used in this analysis. Medicare reimbursement was aggregated for each calendar year. Using the CMS Physician Fee Schedule Relative Value Files, the number of Medicare wRVUs was calculated for each radiation oncologist., Results: In 2015, 4,323 radiation oncologists produced 12,895,298 wRVUs compared with 11,352,286 wRVUs produced in 2012. These datasets include only Medicare reimbursements and do not include wRVUs from private insurance or other payers. In 2015, radiation oncologists produced a median of 2,486 wRVUs from Medicare (range 3 to 24,349). Billing to Healthcare Common Procedure Coding System Code 77427 (radiation treatment management, five treatments), a proxy for total radiation treatments, fell from 1,111,670 in 2012 to 1,039,403 in 2015, a decline of 7%., Conclusion: The total number of wRVUs produced by radiation oncologists has risen by 14% from 2012 to 2015. However, the number of external beam radiation fractions has declined by approximately 7% over this same period, likely due to a trend toward hypofractionated courses of treatment and use of special treatment modalities such as proton beam therapy or stereotactic body radiation therapy., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to assess the potential impact of ACR evidence-based advocacy on radiologist professional reimbursement from individual-provider CMS multiple-procedure payment reduction (MPPR) initiatives., Methods: CMS Physician and Other Supplier Public Use Files and 5% research-identifiable file carrier claims files from 2012 through 2014 were used to identify individual-provider MPPR-eligible services for radiologists (group practice linking unavailability in either dataset precluded quantification of different provider discounting) and then compare actual payments to Medicare Physician Fee Schedule national professional reimbursement rates to identify MPPR-discounted services. Payments attributed to MPPR-affected services and average radiologist annual MPPR discounts were calculated to estimate incremental individual radiologist payment restoration as a result of evidence-based advocacy., Results: Between 2012 and 2014, a mean of 803 to 836 advanced imaging services per radiologist were potentially affected by individual-provider MPPR discounting. Approximately 23% of these services were discounted by individual-provider MPPR, resulting in approximately $2,524 to $2,893 lost per radiologist per year. The MPPR rollback from 25% to 5% is thus estimated to return $55 million to $64 million to radiologists each year for the individual component of MPPR alone., Conclusions: Individual-provider MPPR discounting resulted, on average, in more than $2,500 in lost payments per radiologist per year. Its rollback, associated with ACR evidence-based advocacy efforts, is estimated to return well over $50 million in Medicare professional payments to radiologists each year for individual-component MPPR discounting alone., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: In an effort to curb health care costs and improve the quality of care, bundled payment models are becoming increasingly adopted, but to date, they have focused primarily on treatment episodes and primary care providers. To achieve current Medicare goals of transitioning fee-for-service payments to alternative payment models, however, a broader range of patient episodes and specialty physicians will need opportunities to participate. The authors explore breast cancer screening episodes as one such opportunity., Methods: The authors developed a bundled payment model for breast cancer screening and calibrated it using both a national sample of retrospective Medicare claims data and data from a private health system. The model includes alternative screening episode definitions, methods for calibrating prices, and an examination of risk and can serve as a general framework on which other cancer screening bundles could be crafted., Results: The utilization of services associated with breast cancer screening and diagnosis is stable over time. The inclusion of high-risk patients in breast screening bundles did not cause substantial changes in estimated bundle prices. However, prices are sensitive to the choice of services included in the bundle., Conclusions: Breast cancer screening may provide a mechanism to expand the use of bundled payments in radiology and could serve as a framework for other episodic specialty bundles. Because screening bundles include costs for follow-up diagnostic imaging in addition to the initial screening mammographic examination, patient adherence to screening guidelines may improve, which may have profound effects on public health., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Radiology faces at least three major, potentially fatal, threats. First, as care moves out of the hospital, there will be a decrease in demand for imaging. More care in patients' homes and in other nonhospital settings means fewer medical tests, including imaging. Second, payment reform and, in particular, bundled payments and capitation mean that imaging will become a cost rather than a profit center. These shifts in provider payment will decrease the demand for imaging and disrupt the practice of radiology. Potentially, the ultimate threat to radiology is machine learning. Machine learning will become a powerful force in radiology in the next 5 to 10 years and could end radiology as a thriving specialty., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The Medicare Access and CHIP Reauthorization Act (MACRA) replaces the sustainable growth rate with a payment system based on the Merit-Based Incentive Payment System and incentives for alternative payment model participation. It is important that radiologists understand the statutory requirements of MACRA. This includes the nature of the Merit-Based Incentive Payment System composite performance score and its impact on payments. The timeline for MACRA implementation is fairly aggressive and includes a robust effort to define episode groups, which include radiologic services. A number of organizations, including the ACR, are commenting on the structure of MACRA-directed initiatives., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Radiology in the United States of America is evolving from a fee-for-service to a value-based, "pay-for-performance" system. Such a system requires objective measures, termed metrics, to grade performance. Current grading systems in health care, not designed with the unique nature of radiology in mind, often emphasize patient outcomes; this can be a challenge for measuring and grading performance in radiology, which is often several steps removed from patient outcome. At the present, while there are hundreds of individual radiology-specific metrics, there is no widely accepted overall standard for quality or value in diagnostic radiology services. This article analyzes the current system of radiology metrics and suggests a new direction for performance-based reimbursement in diagnostic radiology, focusing on a limited number of reasonably measurable outcomes-related factors that are specific to radiology., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Bundled or episode payments are among the most heavily emphasized approaches to aligning incentives and promoting care coordination, efficiency, and accountability in health care redesign. Bundled or episode payments price a market basket of services for an entire episode of care with both a clearly defined trigger and termination. Because the radiologist is "ancillary" in many bundles, the specialty is often unaware of the phenomenon. This is likely to change rapidly. Radiology is pivotal in high-prevalence, high-impact care areas such as low back pain and stroke that are focuses of widely used system performance metrics. More important, radiology is central to the diagnosis and management of a wide range of important diagnostic issues in areas such as breast cancer, pulmonary nodules, and incidental findings. Three models of bundled care will probably involve radiology intimately in the near future. Pure radiology bundles might be constructed for breast cancer screening and diagnosis, and these could be priced on the basis of guideline-based best-practice frequencies of care events such as recall and biopsy. Clinical bundles, for example low back pain, could be priced on the basis of optimal imaging frequencies. Finally, pricing of imaging studies might include evidence-based frequencies of follow-up imaging for incidental findings., (Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.)

Purpose: The professional component (PC) Multiple Procedure Payment Reduction (MPPR) policy reduces reimbursement for two or more imaging services rendered by the same group practice for a single patient in a single session. The purpose of this study was to analyze the impact of the PC MPPR on interdivisional finances in an academic radiology department., Methods: A retrospective analysis of Medicare collections from imaging services rendered by a single academic radiology department in a tertiary care medical center for calendar year 2014 was performed. The impact of the PC MPPR on each division was calculated as the fraction of the total departmental PC MPPR, and as the proportion of the divisional revenue., Results: The total decrease in Medicare collections as a result of the PC MPPR was 5.35%. The impact of the PC MPPR on each division as a fraction of the total departmental PC MPPR was: abdominal division (16.63%); thoracic division (23.56%); breast division (0.03%); musculoskeletal division (11.92%); neuroradiology division (34.40%); and noninvasive cardiovascular division (13.46%). The impact of the PC MPPR on each division as a fraction of the divisional revenue was: abdominal (2.82%); thoracic (11.83%); breast (0.66%); musculoskeletal (6.01%); neuroradiology (5.31%); and noninvasive cardiovascular (5.85%)., Conclusions: The PC MPPR differentially affects divisions within an academic radiology department. The neuroradiology and thoracic divisions of our department were the most adversely affected, owing to the high frequency of combined examinations. We speculate that this impact has implications for divisional self-sufficiency, interdivisional relationships, and resident decision making regarding subspecialty training., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The author discusses the economics and regulation of the health insurance industry as they pertain to imaging-based screening programs in light of the Patient Protection and Affordable Care Act., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to quantify potential physician work efficiencies and appropriate multiple procedure payment reductions for different same-session diagnostic imaging studies interpreted by different physicians in the same group practice., Methods: Medicare Resource-Based Relative Value Scale data were analyzed to determine the relative contributions of various preservice, intraservice, and postservice physician diagnostic imaging work activities. An expert panel quantified potential duplications in professional work activities when separate examinations were performed during the same session by different physicians within the same group practice. Maximum potential work duplications for various imaging modalities were calculated and compared with those used as the basis of CMS payment policy., Results: No potential intraservice work duplication was identified when different examination interpretations were rendered by different physicians in the same group practice. When multiple interpretations within the same modality were rendered by different physicians, maximum potential duplicated preservice and postservice activities ranged from 5% (radiography, fluoroscopy, and nuclear medicine) to 13.6% (CT). Maximum mean potential duplicated work relative value units ranged from 0.0049 (radiography and fluoroscopy) to 0.0413 (CT). This equates to overall potential total work reductions ranging from 1.39% (nuclear medicine) to 2.73% (CT). Across all modalities, this corresponds to maximum Medicare professional component physician fee reductions of 1.23 ± 0.38% (range, 0.95%-1.87%) for services within the same modality, much less than an order of magnitude smaller than those implemented by CMS. For services from different modalities, potential duplications were too small to quantify., Conclusions: Although potential efficiencies exist in physician preservice and postservice work when same-session, same-modality imaging services are rendered by different physicians in the same group practice, these are relatively minuscule and have been grossly overestimated by current CMS payment policy. Greater transparency and methodologic rigor in government payment policy development are warranted., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aims of this study were to examine recent trends in the utilization of radionuclide myocardial perfusion imaging (MPI) and to reflect on their causes and their implications for radiologists., Methods: Nationwide Medicare Part B databases for 2000 through 2010 were used. Codes for primary MPI studies (including PET) were selected. Medicare specialty codes were used to identify MPI examinations done by radiologists, cardiologists, and other physicians. Place-of-service codes were used to identify examinations performed in offices versus hospital settings. Utilization rates per 1,000 fee-for-service beneficiaries were calculated. Trends were assessed by place of service and specialty., Results: The overall MPI utilization rate rose from 2000 through 2004, followed by a period of stabilization from 2005 to 2008. A peak of 88.0 per 1,000 was reached in 2006. In 2009 and 2010, a decline occurred, with the rate dropping by 13% to 76.9. In private offices, cardiologists' utilization grew rapidly from 2000 through 2006, but growth stopped thereafter. Their rate peaked in 2008 at 50.6 but dropped to 44.4 by 2010 (-12%). Radiologists' role in office MPI was minimal. In hospital settings, radiologists predominated in 2000. Their rate remained stable through 2004 but thereafter began to decline steadily, dropping by 35% by 2010. Cardiologists' hospital-based utilization rate rose gradually, then flattened, but began to rise in 2009 and 2010. By 2010, cardiologists performed more hospital MPI examinations than radiologists., Conclusions: Radiologists' initially predominant role in hospital-based MPI has eroded recently, while that of cardiologists has strengthened. This seems related to a shift among cardiologists away from office practice and into hospital affiliations., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Radiology benefits management companies have evolved in recent years to meet the need to control the rapid growth in advanced diagnostic imaging. The Obama administration and other key policymakers have proposed using them as a cost-control mechanism, but little is known about how they operate or what results they have produced. The main tool they use is prior authorization. The authors describe the inner workings of the call center of one radiology benefits management company and how its prior authorization program seems to have slowed the growth in the utilization of MRI, CT, and PET in the large markets of one commercial payer., (Copyright 2010 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Self-referral in imaging creates a problem for our health care system in that it leads to higher utilization and costs. Although it is still widespread, there are indications that some states, some regional payers, and the Centers for Medicare & Medicaid Services have begun to take some actions to limit this potentially abusive practice. At the state level, these actions include consideration of anti-self-referral laws, crackdowns on scan-leasing schemes, the institution of mandatory facility accreditation programs, and bans on the installation of advanced imaging equipment in physician offices. Some commercial payers have instituted strict privileging programs in imaging, closed their panels to any facility that is not a full-service imaging provider, and begun requiring accreditation of advanced imaging modalities. The Centers for Medicare & Medicaid Services plans to institute an antimarkup rule and prohibit independent diagnostic testing facilities from leasing space or equipment to nonradiologist physicians, and it has indicated that tightening up the loopholes in the Stark laws may be in the offing. In this paper, the authors review all these recent developments and their implications.

The time seems to be ripe for reforms that will address the rapid growth of self-referral in diagnostic imaging by nonradiologist physicians. The authors present a possible course of action containing six elements that federal or state governments and/or payers could take that would assist them in their efforts to control this ubiquitous problem: (1) a legislative ban on self-referral for certain types of imaging, (2) mandatory accreditation and/or site inspections of all imaging facilities, (3) the limitation of imaging privileges among nonradiologists, (4) the required precertification of all self-referred imaging examinations, (5) the auditing of records of physicians who self-refer, and (6) certificate-of-need laws.