When it comes to medical imaging like CT scans and MRIs, the insurance industry and Medicare have been trying to reduce unnecessary tests. According to a New York Times article, the problem with scans is not just quantity: but it’s also quality. See: http://www.nytimes.com/2009/03/02/health/02scans.html
The article states that insurers pay the same for scans done in old machines and newer models, even though the differences of the images can be significant. The article discusses how insurers fail to distinguish between scans done well or poorly or interpreted by more- or less-qualified physicians.
Differences in scan quality have a real impact on patients and the cost of their care. Linking pay to quality may be difficult in medical imaging. Insurers don’t receive the images and reports, making it impossible for them to know whether the scans are high quality.
This article raises additional issues when it is considered in conjunction with OIG’s 2008 report that from 2000 through 2006 Medicare spending for imaging services more than doubled, increasing to about $14 billion. One reason for the increase was the growth in in-office diagnostic services.
This article raises additional issues when it is considered in conjunction with OIG’s 2008 report that from 2000 through 2006 Medicare spending for imaging services more than doubled, increasing to about $14 billion. One reason for the increase was the growth in in-office diagnostic services.
For practitioners, this article should also be read in conjunction with an understanding of the key provisions of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Under MIPPA, there will be numerous changes which most profoundly affect Independent Diagnostic Testing Facilities (IDTFs) which can be owned by non-medical professionals. Under this law, the changes which include:
■ By 2012, providers of the technical component of advanced diagnostic imaging services must be accredited, at which time CMS may refuse payment to unaccredited suppliers. This includes physician offices. Medicare has not yet developed a list of approved accreditation organizations.
■ By 2010, the Department of Health and Human Services (HHS) Secretary must designate accreditation organizations for suppliers of the diagnostic imaging technical component. CMS will also be conducting a voluntary two-year demonstration project to collect data to determine if advanced diagnostic services are provided appropriately to Medicare beneficiaries.
■ By March 2014, the Government Accountability Office (GAO) must complete a study on accreditation requirements for advanced diagnostic imaging services; specifically, GAO will investigate how required accreditation affects the amount, type, and quality of imaging services provided to Medicare beneficiaries.
■ IDTF facilities and in-office services will continue to be subject to very different standards for staff training and certification. In-office services will remain exempt from the rule requiring IDTFs to use registered radiologic technologists with subspecialty certification for the high-tech scanners they operate.
■ The supervision requirements are also different between IDTFs and in-office settings. The supervising physician for an IDTF must be supervised by a physician deemed proficient in the interpretation of imaging performed with that technology (which is being interpreted as being a board-certified radiologist). In contrast, the supervising physician for an IDTF High-tech equipment in an in-office setting need not be supervised by a physician deemed proficient in the interpretation of imaging performed with that technology. As we understand it, a group practice may designate any of its physicians, regardless of qualifications, to the role.
This new law is in addition to the 2009 Medicare Physician Fee Schedule (MPFS) changes affecting diagnostic studies and IDTFs:
■ Generally, the anti-markup rule prohibits ordering physicians from charging Medicare more for the technical services performed on scanners outside their offices than they paid to rent or lease the equipment. Federal law also prohibits them from billing Medicare for the use of equipment that they own offsite. Under the 2009 rule, claims for the technical component of services are exempted from the anti-markup rule when the physician who supervises the test also performs more than at least 75% of all his or her medical services for the billing physician's practice. Exemption from the anti-markup rule can also be secured by qualifying for the "same building" requirement. This stipulates that equipment is exempted if it's located in the office (or same building) where the billing physician practices.
■ The anti-markup rules still broadly apply to the professional billing component, however. In these instances, the billing physician is prohibited from charging Medicare more than the radiologist is paid to read the imaging study if the study is interpreted at a remote site. Teleradiology and IDTFs will be significantly impacted by this rule. If the radiologist providing interpretation does not bill Medicare separately, then the reassignment of the right to the ordering physician group will be subject to the anti-markup rule.
■ New MPFS rules also require high-tech mobile imaging services to register with CMS as IDTFs. This potentially costly requirement means that mobile services must bill Medicare separately from the healthcare facilities where their mobile equipment visits. The rule even applies to a mobile equipment trailer anchored at a specific site. Until now, mobile services have often billed Medicare through the providers who contract for their services. They have not generally signed on with Medicare as participating providers, much less registered as IDTF. The resulting confusion may require Medicare to clarify, if not modify, its position.
Conclusion: The rules affecting diagnostic studies performed in-office and IDTFs are complex and constantly changing. In addition, the state Medi-Cal laws are different. If your office or IDTF is providing these services, research the new laws, plan for those coming into effect in coming years and make sure you are compliant. Failure to be compliant can result in loss of a provider number, an audit resulting in a significant overpayment or other adverse consequences that can be avoided.
Conclusion: The rules affecting diagnostic studies performed in-office and IDTFs are complex and constantly changing. In addition, the state Medi-Cal laws are different. If your office or IDTF is providing these services, research the new laws, plan for those coming into effect in coming years and make sure you are compliant. Failure to be compliant can result in loss of a provider number, an audit resulting in a significant overpayment or other adverse consequences that can be avoided.
Any questions or comments should be directed to: tgreen@greenassoc.com. Tracy Green is a principal at Green and Associates. They focus their practice on the representation of individuals, businesses licensed professionals, including health care professionals, including IDTFs, radiologists, individual physicians, corporate providers and group practices.
