Mainstream interventional radiology services historically were based in university hospitals and large medical centers. Today, the majority of smaller, community hospitals offer or are expected to offer these same services. Community hospitals and the radiology groups practicing in them are therefore faced with the difficult challenge of providing state-of-the-art interventional services. The delivery of such high-quality services demands a significant time commitment by the physician and support staff, expensive equipment, and a large and costly supply inventory.
In many radiology groups, the philosophy is: everyone does everything. Therefore, the already small volume of interventional radiology business present at these hospitals is diluted among the various physicians. This leads to lower quality due to the lack of expertise and experience in this specialty. Under these circumstances, recruiting an interventionist becomes difficult because there is not enough volume to maintain their interest and expertise.
When there is only one provider specialized in this field, difficulties arise regarding call coverage and availability of service during time off. Many groups burden the interventional radiologist with imaging responsibilities coexistent with the rotation in that subspecialty. Common consequences of this practice are a dilution of attention, stress, overwork, and compromised quality.
In other instances, radiology groups simply ignore this subspecialty altogether, leaving a void that is rapidly being filled by cardiologists, vascular surgeons, neurologists, and urologists eager to garner the additional business.
Following an analysis of our local geography and provider dynamics, we believed that a viable win-win solution was to form an independent interventional radiology practice that could then offer services to various community hospitals. Therefore, in 1996 we formed Endovascular & Interventional Associates Inc. The participating hospitals now have consistent, high-quality interventional radiology services provided by physicians who practice only this specialty. The radiology groups are relieved of this responsibility, allowing them to concentrate on the imaging service. Pooling the volume from the various hospitals supports two full-time interventional radiologists presently and has afforded us the opportunity to promote the specialty. Our volume has increased continuously, which has allowed us to hire an additional interventional radiologist for this coming year. Our current goal is to ultimately service five to seven hospitals with five interventional radiologists.
Establishing a relationship with the hospital that provides turf protection and future security can be challenging. We have found that exclusivity contracts inevitably carry the unacceptable burden of co-termination language (if the service contract is terminated, one must also relinquish medical staff privileges). These privileges seem to be the most durable protection, since one can be expelled only for ethical, moral, or quality breaches. Therefore, changes in hospital affiliation or political or economic factors cannot be motives for eliminating one’s ability to remain a provider. We believe that providing quality service ensures a solid referral base, strengthens political support among the medical staff and administration, and protects against turf erosion. If, in a worst case scenario, the hospital or radiology group hired an interventional radiologist or cardiologist, we could continue to stay, rely on the loyalty of our referral base, and compete.
HANDLING ADMINISTRATIVE ISSUES
Managing the business side of the interventional radiology practice is a very demanding aspect that is critical to survival. Coding, billing, and collecting are of paramount importance and the most difficult and labor-intensive components of administrating the practice. To complicate matters, interventional radiology is probably the most complex specialty to code and bill, because of the mixture of multiple surgical and radiologic codes per procedure. The lack of understanding by carriers of our coding methodology results in repetitive rejections and inappropriate payments, necessitating time-consuming appeals to ultimately receive compensation.
Outsourcing billing services to large regional companies proved unsatisfactory because of their lack of understanding of our specialty and their large volume of other business from specialties with less complicated coding and billing requirements. We therefore decided to recruit a highly qualified business manager with billing expertise and form our own billing service.
Acknowledging that we alone were too small a group to support this venture, we contacted other interventional radiology colleagues in the New England area to handle their billing. This has resulted in a high capture rate for all of us. In addition, a larger group outsourced the interventional radiology portion of the billing practice to our company after realizing they did not have the expertise to maximize revenues for the group in this area. We are advising strongly that radiology groups take a closer look at collections and receivables in interventional radiology. After performing sample billing audits of interventional radiology cases, some groups are concluding that their billing practices related to this specialty are failing as significant monies are being lost. Expertise in interventional radiology billing is a key element to successfully capturing revenue.
THE HOSPITAL RELATIONSHIP
The success of an interventional radiology practice is intimately related to the success of the hospital, since future capital equipment investments and availability of a satisfactory inventory are inextricably related to profitability. In these lean times in which hospitals are compelled to choose where to invest their limited resources, it is essential to ensure that they are being reimbursed appropriately for the interventional radiology services performed. We have found substantial revenue losses related to antiquated billing methodology at each of our participating hospitals, which have since been rectified. In addition, Medicare’s new ability to cross-reference physician and hospital coding demands that an accurate system be in place to avoid compliance violations.
In an effort to further improve service quality, cut expense to the hospitals, and thus increase hospital revenue, we are exploring two new concepts:
- The Traveling Team; and
- Inventory management.
The Traveling Team. This concept entails providing technological and nursing support along with the physician. This relieves the hospital of the burden of staffing the area with full-time personnel for a part-time service. The hospital’s support staff is typically cross-trained from other areas and because of the relatively low volume never gets enough experience to excel. Our staff, traveling with the physician, would participate in a large and diverse volume of cases, maintaining a high level of proficiency. Manpower utilization would be efficiently distributed and call coverage could be provided to small hospitals that are not sufficiently staffed at present to provide on-premises coverage.
Inventory management. The diversity of complex cases performed by interventional radiologists requires a large and expensive inventory, which can be a potential problem for small hospitals that do not wish to tie up capital on the shelf. We believe that maintaining a central large inventory from which stock can be rotated to and from these smaller hospitals would lessen their up-front capital investment and protect against stock expiring on the shelf. Computerized tracking of stock utilization will also allow streamlining of inventory at additional cost savings. Purchasing power will also be enhanced by pooling volume, which should translate into better pricing.
We are in the process of promoting both of these concepts to our participating hospitals.
Interventional radiologists today realize that we have an identity crisis jeopardizing our future. The Society of Cardiovascular and Interventional Radiology (SCVIR) has been active in developing marketing strategies for us to educate the medical community and public at large about our specialty. Our independent practice model dovetails well with this initiative as it develops an identity as a separate specialty rather than as another section of the diagnostic imaging department. Patients and physicians can now associate a physician/group/specialty with a given medical problem or service requirement. This will foster the development of enduring referral patterns, which are ultimately what will ensure the survival of interventional radiology.
NOTE: This is the first article in an occasional series on New Practice Models.
Landy P. Paolella, MD ([email protected]) is a partner in the interventional radiology practice of Endovascular & Interventional Associates Inc, East Greenwich, RI.