Aunt Minnie: The 2020 election and radiology’s future

As the U.S. anticipates the results of the 2020 presidential elections, healthcare continues to be among the biggest concerns for the American people. A faltering economy and a healthcare system devastated by COVID-19 await the attention of the next president. Collaborative Imaging’s CEO, Dhruv Chopra, MBA wrote a piece for Aunt Minnie explaining the implications of the election for practices and radiologists across the country.

Read full article here.

Hospital Hesitates to Share Imaging Prices Upfront, Puzzling Judges And Raising Questions

By Neale Pashley

A hospital hesitated to share Imaging prices upfront with the court. A panel of judges are questioning the hospital field’s hesitancy to share upfront pricing during an appeals case. Why are x-ray prices “unknowable”?

A recent virtual courtroom was recounting a high-profile appeals case. This appeal is by the American Hospital Association who had challenged a Federal policy compelling AHA’s members to publish negotiated rates they reach with insurers for imaging exams and other services. They appealed in a lower court and lost. Now, they are trying again in the D.C. Court of Appeals, which Healthcare Dive reports.

When asked why hospitals cannot produce rates for imaging exams, attorney Lisa Blatt said, “many rates are unknowable.”

But the judges were appeased by this answer. It launched a line of questioning, according to the report.

Judge Merrick Garland asked. “Why is that not doable? Why is it only after Judge Garland leaves the hospital that you know how much to put on Judge Garland’s x-ray charge?”.

Blatt responded that x-ray charges are not easily itemized, and sometimes billed on a volume discount, per diem. But the court continued to express skepticism. “Why? It’s just an x-ray? If I have one, I’ll get charged for $100; and if he gets two, he’ll get $200,” said Judge David Tatel.

While the judges didn’t seem t get the answers to satisfy their questioning, they moved on with the discussion. Keep up to see what the court’s decision will be on the AHA’s appeal with Healthcare Dive.

ASTRO Asks Congress to Delay New CMS Model by Six Months for the Sake of Suffering Clinics

CMS recently unveiled a new payment model for radiation therapy for cancer patients that is set to launch Jan. 1 and expected to save Medicare $230 million over five years.

The Centers for Medicare and Medicaid Services first finalized the model on September 18, creating a bundle-payment system during a 90-day episode of care with radiotherapy providers that treats 16 different cancer types. Their aim was to make more predictable payments in cancer care and incentivize the use of cost-effective treatments. But the effects on Medicare patients and physicians for the sake of saving money are immense. Clinics will suffer the loss of money, there will be lower volumes of care available, and more negative effects.

ASTRO insists that requiring radiation oncologists to start the model so soon will force the already-suffering radiology clinics dealing with staff shortages and other challenges during the COVID-19 pandemic.

The American College of Radiology even penned a letter to federal leaders voicing their concerns over the effects of the program, written by ACR chief William Thorwarth Jr., MD. Thorwarth believes that forcing 30% of radiation oncology clinics is going too far and affecting physicians who are already struggling to survive. The 30% outlined is actually a reduction from what CMS originally wanted, which was 40% of all eligible Medicare radiotherapy clinics nationally.

The proposed happy solution? ASTRO chairman Theodore DeWeese recommended that CMS begin with a voluntary model, and then transition to a mandatory system that will also allow for exemptions for practices with low volume and hardship.

But will Congress agree at this time when the presidential race is up in arms? The impending presidency in January will also have be a major factor in CMS’ decision whether to proceed or not.

2021 Medicare Physician Fee Schedule: Act Now

The Center for Medicare and Medicaid Services (CMS) recently released their proposal for changes to the Medicare payment system which is slated to go into effect on January 1, 2021. According to the American College of Radiology (ACR), the news is not good for radiologists. Those who have analyzed the Medicare Physician Fee Schedule (MPFS) are finding things about the new proposal for radiologists to dislike.

There are many areas of concerns. The primary ones are with the new valuation adjustments, which results in substantial compensation reductions, and the new structuring of evaluation and management (E/M) services. The impact on high-volume radiology procedures is also of concern.

Valuation Adjustments

After all proposed valuation adjustments are considered, CMS estimates the overall impact to radiology will be:

  • 11 percent decrease in payments for Diagnostic Radiology.
  • 9 percent decrease in payments for Interventional Radiology.
  • 8 percent decrease in payments for Nuclear Medicine.
  • 6 percent decrease in payments for Radiation Oncology and Therapy Centers.

These cuts are made necessary by the increase in reimbursement for evaluation and management (E/M) services.

New Coding Structure for E/M Services

ACR notes that there will be a new coding structure for E/M services. This restructuring will allow physicians to choose whether to document and bill for an out-patient office visit according to time spent with the patient, or according to the medical decision-making involved in the visit. This will result in increased payments for E/M services.

The Medicare requirement for budget neutrality means that the increases in E/M payments will cause payments for other services to be reduced.  According to the American College of Radiology (ACR), “If finalized, those changes will result in significant reimbursement cuts to specialties that do not perform E/M services, including radiology.”

Impact on High-Volume Radiology Procedures

The potential impact found on the most frequent radiology procedures can be found in a comprehensive chart posted at the ACR site.  Overall, although the CMS estimate is a 11 percent cut to radiology, HAP analyzed the data and estimates that the decreases in reimbursement will be between 10 and 18 percent. Reimbursement for most procedures will be cut between 11 and 12 percent.

For example, when done at a hospital, the professional component for imaging for an MRI is cut by 8 percent whereas the cut for a CT scan of the brain without dye is 12 percent. A CT Thorax with or without dye is cut by 18 percent. A chest x-ray, one view, is cut by 14 percent, but with two views, the cut is 11 percent.

Response of the American College of Radiology to the Proposed Bill

The ACR is not happy with these changes to the payment system. It prepared a preliminary summary in which it expresses its displeasure over the rule changes. It estimates the new rule will result in substantial reductions in reimbursements to radiologists.

According to some experts, the increase in E/M services by about $5 billion will cost radiologists approximately $770 million in the first year, with an estimated cost of $10 billion over the next 10 years. The ACR notes it “will use every avenue available to work with Congress to modify the impact of these changes.”

The public, and any interested organizations, may comment on the proposed rule. The final rule will be released in November. Meanwhile, Radiology Business reports that a bipartisan group of U.S. House members, in reference to the Medicare budget neutrality requirements, are “asking congressional leaders to quash a Medicare payment change that could cost radiology billions in the years to come.”

How to Take Action to Help Healthcare Practices

One imaging provider, RadNet estimates it will lose $11 million in reimbursement in 2021 if Congress refuses to take action. Representative Bobby Rush, D-Ill, along with 92 lawmakers, wrote a letter to Speaker Nancy Pelosi, D-Calif., and Minority Leader Kevin McCarthy, R-Calif. In which they argued:

it has come to our attention that many specialists are being targeted for ill-conceived and sizable cuts that simply no longer make sense to implement…If these cuts go into effect, they will be devastating for providers and will ultimately result in decreased access to care for patients….Our healthcare system is already under tremendous financial strain, as it continues to grapple with both the economic and health consequences of the coronavirus. Now is not the time to implement these reckless cuts.

The letter writers requested Congress to “waive budget neutrality for Calendar Years 2021 and 2022 for the E/M codes scheduled for implementation on January 1, 2021 as described in the final rule (84. Fed. Reg. 62568, 62847-62860).”

The letter concluded by calling attention to the fact that the country is in the middle of an incredible healthcare crisis with the COVID-19 pandemic, and this is not a time to cut-back on services during this public health emergency.

With 93 members of Congress already urging a wavier of the budget neutrality, now is the time for radiologists themselves to assist Congress by getting involved. Their voices can be heard as they join those of the already-involved Congresspersons who signed the letter to Speaker Pelosi. Every radiologist should call or write their representative and urge them to vote to waive the budget neutrality provision of the MPFS. If enough members of Congress become aware of the impact of those changes on the individual radiologist or radiology practice, the needed change may be possible.

ACR Voices Opposition for Latest Version of Anti-Surprise Billing Legislation

Image courtesy: The Hill

The Lower Health Care Costs Act of 2019, as listed at, originally introduced on June 19, 2019, sought to end surprise medical billing – Anti-Surprise Billing Legislation. The initial bill focused on establishing an independent settlement organization. It also focused to standardize billing and setting thresholds for how companies should approach balance billing for patients. Unfortunately, the legislation stoked uncertainty in the market. And on Tuesday, December 10, 2019, the American College of Radiology (ACR) voiced its disapproval for the latest rendition of the bill. The disapproval is a bipartisan agreement about surprise bills that came to fruition on December 8, 2019.

It is important to note that this agreement has not yet translated into an actual piece of passed legislation. However, it is now much closer to passage with the looming funding deadline in sight. But first, let’s look closer at what the ACR did and did not say regarding the bill.

The Need to Reduce the Rate of Surprise Medical Bills

The ACR does agree with the need to reduce the rate of surprise medical bills. However, the ACR goes on to explain that granting broad powers to insurers to deny claims due to latency in paperwork or limited provider networks would increase risk. Such risks come in the form of denials, even when patients are fully covered and when such test results go beyond the original spectrum and a government-mandated cap on dispute resolution.

The concerns voiced by the ACR also revolve around the financial burden placed on consumers. The bill may grant insurers more wiggle-room to charge higher deductible and co-payments to patients. Meanwhile, provider payments will slow.

A Surprise-ending Piece of Legislation Exists

A past example of a surprise-ending piece of legislation exists, which further supports the ACR position. In August, a study published by the American Journal of Managed Care, reports Kentucky Today, “found bills aiming to reduce the costs of surprise bills typically lead to lower provider payment rates and increased physician group consolidation.” Furthermore, California passed a similar surprise billing law and has experienced a 48% increase in complaints regarding patient access to care. Unfortunately, anti-surprise billing laws tend to result in more network-based practices, lowering competition, and effectively increasing costs to consumers.

Under the agreement struck on December 8, 2019, bills of less than $750 would be paid at the default rate. Meanwhile, bills over that amount would require arbitration, increasing the time between services rendered and payment received, reports

Avoid Another Shutdown

The bill is now part of the upcoming spending bill, which must pass before December 20, 2019, to avoid another shutdown. To gain the favor of Mitch McConnell, the latest agreement includes a mandate to raise the smoking age to 21. Unfortunately, even now, this newest piece of legislation rests in the hands of House and Senate leaders. Congress has less than one week to work out any remaining details of the spending bill. This is done to transform the once-dimming view of surprise billing into a signed law.

For now, the legislation is still a piece of a bill, and the growing backlash from the ACR and other health entities may lead to another stall. However, this is a precarious time for the industry. If the legislation passes, either as an independent bill or part of the spending bill, it will have wide-ranging ramifications that shudder through the industry. Now the waiting game begins, and private practitioners, including radiologists, need to start thinking about how they can work with patients and insurers alike to get their fair share of payments and avoid delays under the new anti-surprise billing legislation. As of December 13, experts do not expect the legislation to pass this year, reports Peter Sullivan of the Hill. Please stay tuned. We will provide another update as this legislation moves through Congress.

Lawsuit Over Failed Follow-Up for CT Findings Settled Out of Court

Could have the lawsuit over failed follow-up for CT findings been avoided? On March 24, 2014, Cynthia Hawthorne was experiencing pain in the lower, left side of her abdomen. She decided to seek treatment at the Brattleboro Memorial Hospital’s (BMH) emergency department. To determine the reason for her abdominal pain, a computed tomography (CT) scan was ordered. The emergency room physician suspected that she was suffering from diverticulitis, and According to the CT scan results,  she was.

However, she also had a highly suspicious renal mass in her left kidney. Hawthorne was unaware of this mass and the emergency department physician neglected to inform her of these findings. By the time she was informed of the mass more than two years later, it had already developed into renal cancer that had spread to her lungs. On March 2, 2019, she passed away due to complications related to her renal cancer.  Despite her passing, her son was able to move forward with her malpractice lawsuit. In September 2019, Hawthorne’s suit against the hospital, clinic and radiology group was settled out of court, for an undisclosed amount.

Hawthorne Visits the Emergency Department at Brattleboro Memorial Hospital

Hawthorne decided to visit BMH’s emergency department on March 24, 2014, because she was suffering from abdominal pain. She received pain medication, intravenous liquids and a computed tomography scan of her abdomen during the visit. The scan was ordered to determine if she had diverticulitis. Diverticulitis occurs when small pouches (diverticula) that have formed in the colon become infected or inflamed. Her CT scan showed that she was suffering from this infection. But the scan also indicated that there was a mass in her left kidney. The radiologist referred to this mass as being highly suspicious for renal cell carcinoma.

Initially, the CT scan performed on March 24, 2014, stated that Hawthorne’s left kidney looked normal. However, later that day, an addendum was added to her report noting that further evaluation revealed a mass in her left kidney.

The radiologist spoke with an emergency department physician about Hawthorne’s renal mass and made several recommendations concerning follow-up. Despite the radiologist’s recommendations for Hawthorne to have the mass biopsied and then to follow-up with a urologist, she was discharged from the Brattleboro Memorial Hospital’s emergency department that same day. Hawthorne left the emergency department with instructions on how to manage her diverticulitis and a prescription for antibiotics. Hawthorne was never informed of the renal mass.

The Claim: Hospital Staff Neglected to Exercise Reasonable Care

Hawthorne’s lawsuit claimed that Brattleboro Memorial Hospital failed to inform her, in a timely manner, of the highly suspicious mass that was identified in her left kidney during a CT scan that was performed on March 24, 2014.

Hawthorne’s medical malpractice case involved three entities:

  1. Brattleboro Memorial Hospital — which is the facility where she received her emergency treatment.
  2. Dartmouth-Hitchcock Clinic — which is the company that runs the emergency department at Brattleboro Memorial Hospital.
  3. Windham Radiology Associates — which is BMH’s in-house radiology group.

Hawthorne also filed a civil suit against Brattleboro Memorial Hospital and Dr. George Terwilliger, who was the director of the hospital’s emergency department  at the time of her visit

According to court documents, Dr. Terwilliger was the physician who discussed Hawthorne’s CT results with the Windham radiologist who discovered the mass on March 24, 2014. Although the two agreed that further evaluation was necessary, the Windham radiologist, the hospital and Dr. Terwilliger neglected to continue investigating the mass through additional evaluations, and/or tests. Furthermore, they failed to inform Hawthorne that she had a renal mass.

On March 17, 2017, the Division of Licensing and Protection Visits BMH

The Division of Licensing and Protection (DLP) visited BMH seeking information about Hawthorne’s care. According to the DLP report, one of the radiologists with Windham Radiology Associates did issue a warning concerning the mass located in Hawthorne’s left kidney. Although Windham’s radiologist recommended that Hawthorne have a biopsy performed and then follow-up with a urologist, this information was never communicated to the patient.

The DLP Cites BMH for Violations Related to Hawthorne’s Care

The Brattleboro Memorial Hospital received two citations from the DLP. One was for violating Hawthorne’s rights of being informed of her health status as well as her right to be actively involved in the planning of her care and treatment, including for her right to either request or refuse treatment. The other citation referenced BMH’s failure to thoroughly investigate why Hawthorne never received her CT results.

Hawthorne’s 2012 Abdominal Scan Also Revealed the Renal Mass

Hawthorne’s March 24, 2014 visit to the emergency department at Brattleboro Memorial Hospital for abdominal pain was not the first time she sought treatment there for this problem. On Jan. 23, 2012, she went to BMH’s emergency department complaining of abdominal pain. At that time, Hawthorne also had a CT scan, which revealed a small renal mass in her left kidney. Despite the scan being conducted and read by radiologists, physicians, employees, providers, contractors and/or agents of Brattleboro Memorial Hospital, her patient report does not even mention the renal mass that was found on her 2012 CT scan.

Hawthorne Finally Learns of the Mass

On Sept. 26, 2016, Brattleboro Memorial Hospital informed Hawthorne for the very first time that she had a mass in her left kidney. A mass that could be cancerous. This is two-and-a-half years after her March 2014 emergency department visit, and four years after her January 2012 emergency department visit.

By the time Hawthorne was informed of the mass, it had already developed into renal cancer that had spread to her lungs. In addition, this delay in treatment resulted in Hawthorne requiring emergency surgery to remove her left kidney. She underwent chemotherapy as well as other treatments that caused her a tremendous amount of pain.

Despite all the treatment, Cynthia Hawthorne passed away due to renal cancer on March 2, 2019. She was only 58 years old. On April 25, 2019, Hawthorne’s attorneys filed an amended complaint naming her son, Justin Johnston, as the new plaintiff. The case finally settled for an undisclosed amount in September 2019.

The delays that resulted in this tragic loss could’ve been avoided

Dhruv Chopra, CEO of Collaborative Imaging, states, “The delays that resulted in this tragic loss could’ve been avoided”.

He continues to explain that, “Expectations placed on radiologists continue to grow. Gone are the days where a radiologist’s job is limited to viewing images and rendering interpretations. Today, radiologists have to take on more administrative tasks, and unfortunately, in some cases clerical work, to ensure their diagnostic interpretation is delivered and action is taken at the same time. Despite these growing demands placed on radiologists, reimbursement for interpretations continues to decline, and, given the shortage of radiologists, this additional work effort, in conjunction with lower reimbursements has resulted in the growing burn-out-rate that is plaguing the radiology industry.

“The expectations that referring physicians and healthcare executives place on radiologists are not necessarily un-achievable. However, technology solutions must be deployed to facilitate those demands.”

The other missed opportunities that may have saved Hawthorne’s life:

  • On March 27, 2014, and April 14, 2014, Hawthorne was seen again; however, neither time did her providers note that she had a left renal mass.
  • On June 19, 2014, Hawthorne saw one of BMH’s physicians. Despite finding the renal mass on Jan. 23, 2012, and seeing the mass again on March 24, 2014, the physician’s note does not mention that the mass was ever discussed with Hawthorne.

Preventing Missed Opportunities

There is no doubt that a radiologist has a role to play in relaying abnormal findings. To this end, Collaborative Imaging has developed a state-of-the-art solution to identify and notify referring physicians of such abnormal and critical findings. Collaborative Imaging’s CEO, Dhruv Chopra says, One reason why consolidation is growing in the radiology industry is that groups are not being able to cope with the increasing demands placed on radiologists.

So, we had to do something to preserve the practice of independent radiology. Our solution is designed to allow radiologists to focus on their studies. Also, ensuring the necessary processes such as identifying the correct referring physician and their preferred notification method is adhered to and all abnormal findings are relayed in a time-sensitive manner. Our solutions have returned to the radiologist their very valuable time. The time they use to render patient care by interpreting studies in a more efficient manner.

Some of the benefits of Collaborative Imaging’s notification software include:

  • A real-time solution designed to identify any anomalous studies with built-in escalations and notifications.
  • These notifications can be customized to meet the needs of the referring physician, or hospital system, such as relaying the notification directly to the referring physician through our secure, proprietary applications or just passing the same on to the hospital system’s electronic medical record. electronic medical records
  • Interactive sharing of key images with a one-touch, real-time video conference between the radiologist and referring physician.
  • Real-time logging and reporting of all actions and notifications taken
  • Immediate feedback to update the radiologist interpretation to conform to compliance and documentation requirements reflecting who was notified of the findings and at what time.

What Dhruv Chopra Says

Dhruv Chopra says, “Our solutions are designed to help ensure cases such as Hawthorne’s do not occur in the future. By taking a holistic view of the delivery of care in conjunction with our decades of experience in the healthcare space, we have been able to apply our proprietary computer-aided technology to workflow processes to ensure a repeatable and reliable approach is in place to identify and relay critical, incidental, and abnormal findings.

Radiologists, administrative, and clinical staff are actively involved throughout the process as appropriate. But we do not lose sight of the fact that radiologists are highly qualified and specialized, and as such should not be spending their valuable time performing clerical tasks such as trying to find out who the referring physician is or obtain the correct number to call a referring physician.”

Dhruv Chopra twitter



Breakdown of percentage of claims against radiologist from a malpractice perspective ie ER, IP, OP

While literature based on errors made in radiology and the malpractice cases that may result is prevalent, information related to systematic reviews of the actual malpractice claims is lacking. However, on Aug. 27, 2019, the Journal of the American College of Radiology published the study, Emergency Radiology: An Underappreciated Source of Liability Risk. According to this study, nearly 50 percent of all the malpractice claims related to radiology involve patients who received treatment in the emergency department/emergency room.

Malpractice Claims Against Radiologists: Inpatient, Outpatient and Emergency Room Patients

The authors of the study explored imaging examinations that spanned 18 states. All the 149 radiology images studied were from cases that took place at some point between 2012 and 2019. The evidence used for the study was attained from a platform in Seattle called Cleareview.  Other data reviewed included Medicare data. The researchers used this data to locate the number of imaging examinations that were performed in emergency departments throughout the country.

The results of the study conclude that the percentage of radiologist malpractice claims associated with the place of service/type of patient are as follows:

  • Emergency room/emergency department — 46 percent.
  • Inpatients — 17 percent.
  • Outpatients — 38 percent.

Malpractice Claims: ED Radiology Examinations vs. the Medicare Cohort

This study finds that the likelihood of a malpractice claim resulting from an emergency room radiology examination was almost four times higher than the portion of emergency department exams in the Medicare group, which raises the potential that emergency room radiology examinations are more likely to lead to this type of claim than an inpatient or outpatient claim is.

What Causes this Imbalance in Emergency Department Examinations?

The authors of the study believe there are several factors that may be contributing to this lack of balance. One factor was the limitations of Clearview’s database as it only has cases that are presumed to be appropriate for a blind view. Therefore, when malpractice issues relate to procedural complications, communication failure or complaints related to consent, the imaging examination information may not be included in the Cleareview database.

Reasons for an Increase in the Risk for Malpractice Claims in the ER

In the end, the researchers believe their findings offer support to the inference that emergency room examinations pose an increased risk when it comes to malpractice claims for radiologists. One reason for this increased risk could be the numerous specialists that emergency department studies are distributed to. Another issue is the coverage hours and pace that is demanded of emergency radiology staff, which may cause a rise in errors related to diagnosing. Sometimes, radiologists who are working in emergency departments do not have the skills necessary to identify crucial details that only a radiologist with subspecialty training would recognize.

Coverys’ Red Signal Report — An Overview of Diagnose-Related Claims

Robert Hanscom is the vice president of business and analytics at Coverys Insurance. He also wrote the Red Signal Report. While creating this report, Hanscom worked alongside his colleagues to analyze over 10,000 closed claims. As they researched, they focused on identifying any safety vulnerabilities and sizable risk factors for the claims that were filed between the years of 2013 and 2017.

Key Findings of the Red Signal Report

Approximately 15 percent of all the diagnosis-related malpractice claim allegations involved radiologists. An enormous number of these diagnosis-related malpractice claims (80 percent) occurred due to clinical test misinterpretations. And over 80 percent of these cases involved the patient suffering with a serious injury or resulted in the patient’s death. The most common misdiagnosis among the radiology malpractice claims that alleged diagnostic failure was cancer, with the most prevalent being breast, pancreatic, lung and ovarian.

A Section of the Report Recommends Standard Treatment Protocols

One section of the Coverys’ report addresses risk recommendations. Recommendations specifically for the radiology department. These recommendations include the adopting decision support film practices, creating standardized treatment protocols and developing templates to use for reporting. In addition, the team suggests separating their recommendations and incidental findings from the other parts of the imaging report as well as implementing checklists, using clear, concise language to reduce the likelihood of a misunderstanding, while embracing new improvement methods.

According to Hanscom, radiologists play a vital role in delivering an accurate diagnosis. He states that learning from mistakes that were made in the past and identifying the areas that are most prone to mistakes could proactively reduce the number of errors before ever reaching the patient; thus, improving the patient’s overall outcome.