Radiologists possess great power and skill in the health care industry. As health care evolves, the way radiologists bill for services continues to change. Earlier this year, the Centers for Medicare and Medicaid Service (CMS) enacted a law requiring health practices to provide clear access to prices for their care. Yet, that only forms a section of the problems facing radiology. Radiology remains a field where insurers may not always cover a service, and depending on the relationship with a given facility and external radiology practices, patients were left on the hook for balances. However, new legislation in key states, such as New Jersey, looks to eliminate these costs and protect patients. Failure to know recent legislation and regulations governing the billing from out-of-network practices and even release of incidental findings opens the door to risk. Radiologists may face stiff fines and penalties for violations of these compliance measures.
What Are Surprise Bills and What Does Legislation Say About Them?
A surprise bill occurs when an out-of-network practice bills a patient for services rendered when an in-practice physician refers the patient the imaging center. This situation tends to occur when a patient in need of urgent or emergency care visits an in-network facility, and that facility uses an out-of-network practice for imaging services. The patient is none the wiser as to the out-of-network nature of the radiology practice, receiving a bill in the future for the balance owed when services were ordered out or contracted by an in-network facility.
As explained by Info.HAPUSA.com, the recent legislation out of New Jersey specifically limits the amount a care provider can bill a patient for out-of-network services when provided on an emergency or urgent basis. The law contains precise language further iterating “inadvertent out-of-network services.” As an added example, an in-network hospital contracting with an out-of-network radiology practice means the radiologist cannot bill more than the limit applied to the hospital for radiology services. This eliminates the risk to patients, but it places a burden on radiology practices. As a result, radiologists must work to either gain in-network status or negotiate new contract rates with hospitals for exclusivity or other means to compensate for costs lost.
Radiologists Working With Hospitals Fall Under Price Transparency Rules.
Radiologists are subject to the same stringent criteria set forth the CMS, including new price transparency rules. According to CMS.Gov, price transparency regulations empower patients with transparency into specific medical costs. The idea is to offer patients an end-to-end view of the cost of health care and improve access. In-house radiologists have always fell under the regulations governing hospitals, but under the new regulations, off-site and external radiology practices must publicize rates for all services. In addition, the new law offers the promise of equitable rates charged by rural areas, which have suffered from years of higher costs and decreased reimbursement due to an inability to compete with the cost of urban care centers. Of course, such transparency increases the administrative work for radiology practices.
Incidental Findings Lack Regulation, But Radiologists Must Beware of Local Laws.
Radiologists have always faced uncertainty when unexpected findings arise from other images. Should the findings be reported to patients, or should they be sent over to the primary care physician (PCP) for release to the patient. Moreover, the evolution of imaging technologies has brought findings once too small to identify, including masses, tumors and cysts, to the center of results, even when an image is for another purpose. As reported by Radiology Business, the American College of Radiology (ACR) is working to identify the best practice for managing such findings, but uncertainty remains.
Even if every small finding was reported, do radiologists really have a duty to report them to patients, and if so, what are the ramifications for releasing information that may incessantly worry patients and their families? Discovering something that could harm a person comes at a high cost, and it is important to balance the risks versus benefits of identifying and releasing such findings. More importantly, the sharp increase in the rate of incidental findings has led some governments to begin consideration of laws and legal regulations regarding such findings, as exemplified in a genomic imaging study and reported by the National Library of Medicine. Unfortunately, the exact legal statue does not exist today, and all releases of incidental findings remain subject to broad interpretation and even risk for legal consequences.
Each court carries the responsibility and power to interpret laws governing findings’ release, so little can be accomplished in the way of maintaining incidental findings’ release to patients, regardless of ACR recommendations. Moreover, radiologists do have the authority to release such findings to patients. Instead of risking their careers, radiologists should release such findings back to the referring physician and pass the risk along to an appropriate care provider. This lowers the level of legal liability, and of course, it hinges on documenting such findings’ communications and efforts to notify a referring physician.
Ongoing Legislation Aims to Incorporate Off-Site Radiology Into Medicare Reimbursement and Boost Patient Access to Care.
Another piece of legislation that has not yet been passed will affect radiology in the coming years. It revolves around Medicare reimbursement for radiology services. According to the American Society of Radiologic Technologists, the Medicare Access to Radiology Act of 2019 would align state and Medicare reimbursement policies for reimbursement of services. This law would ensure reimbursement for radiology services regardless of where the service was performed. In a sense, this proposed law would blend the surprise bill legislation with Medicare-enrolled patients. As a result, radiology practices can obtain reimbursement under Medicare, virtually eliminating the need to bill Medicare patients in the first place. Such actions would increase access to advanced imaging capabilities for areas with limited Medicare-accepting radiology practices, especially in rural areas.
What Should Radiologists Do About New Legislation Right Now?
Radiology remains a sector of health care subject to isolationist practices. Despite the costs and challenges in radiology, practitioners provide a vital service to the health industry, delivering results for patients suffering emergencies and in need of routine imaging services. To ensure patient safety and quality assurance, government regulation continues to focus on radiology. The results of such focus suggest radiologists will face additional struggles in managing practices and obtaining payments from patients. However, actual implications of changing legislation will reduce rate of complaints, build positive patient-practice interactions and provide access to new revenue streams for a sector often wrought with unpaid high-balance bills. The landscape is changing, and these changes in legislation are a win for both private radiologists and those considering building their practices through partnerships and local access to imaging services.