Coordinated participation is the key to radiologists’ influence on reimbursement policy.

Can one radiologist have an influence on reimbursement? According to a panel convened at the 89th Scientific Assembly and Annual Meeting of the Radiological Society of North America, the answer is a definite yes.

The panel, moderated by Pamela Kassing, of Reston, Va, in association with the American College of Radiology (ACR), featured presentations by five speakers, of which the first were James Paul Borgstede, MD, of Colorado Springs, Colo, and Peter H.B. McCreight, MD, of La Jolla, Calif.

Borgstede and McCreight initiated the discussion by explaining the meaning of common acronyms with which radiologists should become familiar and the purpose of the various entities that they define. The Resource-Based Relative Value Scale, or RVS, is developed by the American Medical Association with input from the specialties (the American College of Radiology represents radiology) on the basis of components including physician work (time and intensity) and practice expense (staff labor time, medical and office supplies, and equipment). These components are overseen by the Practice Expense Advisory Committee, or PEAC. The RVS Update Committee, or RUC, implements the RVS and revises it in association with the PEAC.

Borgstede described the process in which the RUC surveys radiologists about practice particulars, compiles the data, and studies the findings for indications of reimbursement changes that may be necessary.

McCreight explained that one way in which the RUC influences reimbursement policy is through the valuation of CPT codes, on the basis of the results of these surveys. In fact, the committee participates in the creation of an average of 750 new or revised codes per year. Radiologists can have input in these changes by joining the ACR and serving on the RUC, PEAC, and CPT committee. Because adequate reimbursement is critical to radiologists’ ability to meet their practice expenses, McCreight urges practitioners to become involved with such committees.

Another way in which the RUC exerts influence is by generating comment letters about policy changes to the Centers for Medicare and Medicaid Services (CMS). In turn, the CMS participates in RUC meetings about CPT code valuations. Recent successes of the RUC have included participating in a CMS validation panel and gaining expanded coverage for MRI and positron emission tomography (PET). Current issues before the RUC involve the shift in procedures from hospital to office sites and changes in the conversion factor


Bib Allen, Jr, MD, of Birmingham, Ala, next described to the RSNA audience how local Medicare reimbursement works. The CMS contracts with private insurance carriers to administer Medicare claims in particular states (one or more). Thus, most policies are local rather than national (in fact, 95% of Medicare coverage decisions are determined locally). Each carrier has a medical director (known as the contractor medical director, or CMD), who establishes the local policies with other CMDs. The CMD determines the medical necessity of procedures and thus their reimbursement status. Radiologists can provide input on these decisions by serving on a policy advisory committee known as the Medicare Carrier Advisory Committee, or CAC. Such participants would represent the radiology field in the process of adding ICD-9 codes necessary to radiology practice.

The impact of the CAC representatives is most evident in the network they form to coordinate a response to unfavorable policy and to promote favorable policy. In addition, radiologists and subspecialists can participate in a committee comprising practitioners in each state, known as the State Medicare Advisory Committee. This entity enables a unified response to carrier medical directors. As Allen notes, “We believe coordination is the key, to have a unified message go to the carriers.”

John A. Patti, MD, of Salem, Mass, spoke next on dealing with third-party payors. Patti encourages radiologists to avail themselves of the advantages of ACR membership, especially because its national interaction provides the most effective means of dealing with private providers, who account for two thirds of radiologists’ revenue. The ACR conducts systematic reviews of all CPT radiology code edits, for instance. The organization also meets with national medical directors and provides input early in the policy evaluation process. “The ACR strives to be proactive rather than reactive,” Patti emphasizes.

ACR member resources include a Web site and email news delivery; an electronic bibliography on literature addressing the cost-effectiveness of radiology procedures; a Web-based discussion forum; and management of individual member issues. The ACR is also developing an educational series on claims management.

Patti advises radiologists to form a local Radiology Advisory Committee and then to schedule quarterly meetings with third-party payors. They can then use these gatherings as a means of interacting with payors on a formal and informal basis and thus as a tool for motivating them. These personal interactions may be the most important key to influencing policy. “Effective interaction must be a grassroots process that begins at the local level and is implemented at the national level,” Patti asserts.

To conclude the panel on influencing reimbursement, William T. Thorwarth, Jr, MD, of Hickory, NC, who is president of the ACR, spoke on the Hospital Outpatient Prospective Payment System (HOPPS), which was driven by the rapid rise in Medicare outpatient expenses and was implemented in August 2000.

Thorwarth explained that radiological procedures account for a large portion of Medicare claims: more than 50% of Medicare outpatient costs are for either outpatient surgery or radiology. Thus, accurate cost data and hospital charge systems are essential to the radiology profession. “We have never been equipped with a better knowledge base for taking care of our patients,” he noted, “but the viability of our profession depends on adequate reimbursement.”

With the implementation of HOPPS, multiple procedure-related expenses are packaged together under one procedure code, with no consideration given to additional costs. Radiologists therefore must make sure that the codes reflect the appropriate charges so that the actual costs of services are covered. In addition, because of current reimbursement challenges, it is more important than ever for departments to consider whether equipment acquisitions and software upgrades are cost-effective.

Seleen Street Collins is a contributing writer for Decisions in Axis Imaging News.

Becoming Involved

According to RSNA panelist Peter H.B. McCreight, MD, of La Jolla, Calif, radiologists can become involved in the development of reimbursement policy in the following ways:

  • join the ACR, which to date has refined more than 4,000 codes;
  • volunteer to participate in surveys, from which data are used to change policy;
  • supply accurate data to ACR committees, because the accuracy of members’ input is essential to its application; and
  • communicate with insurance carriers, especially because education of carriers is an important activity.

In addition, panelist John A. Patti, MD, of Salem, Mass, advises that radiologists form a local Radiology Advisory Committee and schedule quarterly meetings with third-party payors. There are several tools with which radiologists can motivate payors with such a platform:

  • be diplomatic and strive to help them understand a procedure;
  • be persistent;
  • develop personal contacts and relationships with payors;
  • give interesting and relevant presentations at committee meetings;
  • in your interactions with payors, be cordial to lower-level staff members (who might be future medical directors); and
  • allow time for casual conversation with payors at meetings.