Search

Out-of-network (OON) balance billing, commonly known as surprise billing but better described as a surprise gap in health insurance coverage, occurs when an individual with private health insurance (vs a public insurer such as Medicare) is administered unanticipated care from a physician who is not in their health plan's network. Such unexpected OON care may result in substantial out-of-pocket costs for patients. Although ending surprise billing is patient centric, patient protective, and noncontroversial, passing federal legislation was challenging given its ability to disrupt insurer-physician good-faith negotiations and thus impact in-network rates. Like past proposals, the recently passed No Surprises Act takes patients out of the middle of insurer-physician OON reimbursement disputes, limiting patients' expense to standard in-network cost-sharing amounts. The new law, based on arbitration, attempts to protect good-faith negotiations between physicians and insurance companies and encourages network contracting. Radiology practices, even those that are fully in network or that never practiced surprise billing, could nonetheless be affected. Ongoing rulemaking processes will have meaningful roles in determining how the law is made operational. Physician and stakeholder advocacy has been and will continue to be crucial to the ongoing evolution of this process. © RSNA, 2021.

Many believe that fundamental reform of the U.S. health care system is overdue and necessary given rising national health care expenditures, poor performance on key population health metrics, meaningful health disparities, concerns about potential financial toxicity of care, inadequate price transparency, pending insolvency of Medicare Part A, increasing commercial insurance premiums, and large uninsured and underinsured populations. The Medicare Payment Advisory Commission, an independent congressional agency, believes that part of this reform includes redistribution of reimbursements away from specialties such as radiology. Thus, despite an increase in the Medicare population and spending, Medicare payments for medical imaging have been decreasing for years. Further, the No Surprises Act, a federal law intended to curb the problem of surprise medical billing, was repurposed in federal rulemaking to reduce reimbursement from commercial payers to certain specialties, including radiology. In this article, we examine challenges facing the U.S. health care system, focusing on cost, reimbursement, and price transparency and the role of radiology in addressing such challenges. Medical imaging is a minor contributor to national health care expenditures but has an outsized impact on patient care. The radiology community should work together to reinforce the value of medical imaging and reduce inappropriate utilization of low-value care.

The purpose of this article is to outline practical steps that a department can take to transition to a peer learning model.The 2015 Institute of Medicine report on improving diagnosis emphasized that organizations and industries that embrace error as an opportunity to learn tend to outperform those that do not. To meet this charge, radiology must transition from a peer review to a peer learning approach.

A major outcome of the current health care reform process is the move away from unrestricted fee-for-service payment models toward those that are based on the delivery of better patient value and outcomes. The authors' purpose, therefore, is to critically evaluate and define those components of the overall imaging enterprise that deliver meaningful value to both patients and referrers and to determine how these components might be measured and quantified. These metrics might then be used to lobby providers and payers for sustainable payment solutions for radiologists and radiology services. The authors evaluated radiology operations and services using the framework of the imaging value chain, which divides radiology service into a number of discrete value-added activities, which ultimately deliver the primary product, most often the actionable report for diagnostic imaging or an effective outcome for interventional radiology. These value activities include scheduling and imaging appropriateness and stewardship, patient preparation, protocol design, modality operations, reporting, report communication, and clinical follow-up (eg, mammography reminder letters). Two further categories are hospital or health care organization citizenship and examination outcome. Each is discussed in turn, with specific activities highlighted.

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.

As a result of macroeconomic forces necessitating fundamental changes in health care delivery systems, value has become a popular term in the medical industry. Much has been written recently about the idea of value as it relates to health care services in general and the practice of radiology in particular. Of course, cost, value, and cost-effectiveness are not new topics of conversation in radiology. Not only is value one of the most frequently used and complex words in management, entire classes in business school are taught around the concept of understanding and maximizing value. But what is value, and when speaking of value creation strategies, what is it exactly that is meant? For the leader of a radiology department, either private or academic, value creation is a core function. This article provides a deeper examination of what value is, what drives value creation, and how practices and departments can evaluate their own value creation efficiencies. An equation, referred to as the Total Value Equation, is presented as a framework to assess value creation activities and strategies.

Recent political and economic factors have contributed to a meaningful change in the way that quality in health care, and by extension value, are viewed. While quality is often evaluated on the basis of subjective criteria, pay-for-performance programs that link reimbursement to various measures of quality require use of objective and quantifiable measures. This evolution to value-based payment was accelerated by the 2015 passage of the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA). While many of the drivers of these changes are rooted in federal policy and programs such as Medicare and aimed at adult patients, the practice of pediatrics and pediatric radiology will be increasingly impacted. This article addresses issues related to the use of quantitative measures to evaluate the quality of services provided by the pediatric radiology department or sub-specialty section, particularly as seen from the viewpoint of a payer that may be considering ways to link payment to performance. The paper concludes by suggesting a metric categorization strategy to frame future work on the subject.

Whether a doctor, professional baseball manager, or a politician, having successful negotiation skills is a critical part of being a leader. Building upon prior journal articles on negotiation strategy, the author presents the concept of the multiple equivalent simultaneous offer (MESO). The concept of a MESO is straightforward: as opposed to making a single offer, make multiple offers with several variables. Each offer alters the different variables, such that the end result of each offer is equivalent from the perspective of the party making the offer. Research has found several advantages to the use of MESOs. For example, using MESOs, an offer was more likely to be accepted, and the counterparty was more likely to be satisfied with the negotiated deal. Additional benefits have been documented as well, underscoring why a prepared radiology business leader should understand the theory and practice of MESO.

In my first week of business school, an MBA program for executives, the professor asked people to raise their hands if they considered the industries they were in to be both highly competitive and increasingly challenging. The group of students in the classroom was quite diverse. Represented were the oil and gas industry, investment banking, construction, and even a private intelligence agency, among many others. Every single person in the class raised their hand. It may have been the only time our class had complete agreement. So, with the understanding that everyone thinks their own industry is particularly competitive, I nonetheless contend that radiology is facing unique and unprecedented challenges. The future viability of any radiology practice will depend in very large measure on how its members recognize and respond to these novel challenges. Previously, the greatest threat to any private radiology group was displacement by a competing group, typically from the same city. Today, practices remain threatened from local groups but now also face the aditional threat of displacement by ational teleradiology outsourcing rms. Of additional concern is enanced competition from local roups that themselves were dislaced by teleradiology outsourcing rms. Furthermore, many groups re disappearing as radiologists are ecoming direct employees of the ospitals. This competitive landcape exists during a time of major pheaval in the health care environent as well as in an environment f state and federal budget shortalls. So, at the same time as a comletely new way to staff radiology epartments has emerged, thanks o technological advances, there is