Local, State, Federal
Accreditation Ensures Quality, Guarantees Payment
The Bill Box
HealthHelp Certified by NCQA
Illinois Attorney General Intervenes in MRI Kickback Lawsuit
Health Plans Ramp Up RBM Programs
Maximize Mammography Reimbursement
Accreditation Ensures Quality, Guarantees Payment
By Dana Hinesly
To improve quality uniformly across all of its participating locations, the UnitedHealth Group, Minneapolis, has launched the UnitedHealthcare Imaging Accreditation Program. The program—which is structured around accreditation standards developed by the American College of Radiology (ACR) and the more than 22 sponsoring organizations of the Intersocietal Accreditation Commission (IAC)—requires that all providers of outpatient imaging services obtain accreditation as a condition for reimbursement from UnitedHealthcare. Modalities subject to the new stipulation are CT, CT angiography (CTA), MRI, MR angiography (MRA), nuclear medicine, nuclear cardiology, PET, and echocardiography, effective March 1, 2008.
“These accreditation programs ensure that equipment, technologists, and physicians are in compliance with appropriate performance standards for imaging procedures,” says Laurie Paidosh, director of radiology programs at UnitedHealthcare. “In diagnostic imaging, accreditation programs have emerged as key initiatives to advance the quality and safety of imaging studies, particularly in these areas.
“Given the specialized physician experience and advanced technology required in these procedures,” she continues, “it is important that consumers receive services from facilities whose equipment, technologists, and physicians are in compliance with established accreditation performance standards for these procedures.”
Facilities can apply for accreditation from either the ACR or IAC, following the established processes. To comply, it is necessary to obtain accreditation from only one of the organizations. Neither agency has adjusted its accreditation requirements to fit any specific guidelines from UnitedHealthcare. According to Paidosh, the entire process takes an average of 6 to 9 months.
“UnitedHealthcare is one of the largest insurers in the country, which makes this the first time accreditation has been required on a nationwide scale,” explains Shawn Farley, public relations manager for the ACR. “This is a pretty big step, and since this announcement was made, we already are seeing facilities start the accreditation process.”
ACR accreditation also verifies that physicians meet all qualifications, and Farley expects that facilities seeking accreditation will expand beyond radiology centers and include those providing cardiology services, among others.
“The ACR is the oldest and most widely recognized accrediting body for imaging and radiation oncology facilities in the country,” Farley says. “For unaccredited facilities, we believe it will raise the quality of care. Accreditation signifies that the technologists are certified by the appropriate body, that the doctor interpreting the exams satisfied certain educational or training requirements, and that the equipment itself has been surveyed regularly by a medical physicist to make sure it is functioning properly.”
UnitedHealthcare advises facilities to follow the application instructions carefully and completely to expedite the accreditation process, noting that the more organized an imaging site is, the easier it will be to complete the accreditation application. It also recommends that applications be submitted immediately to avoid any risk of not making the deadline.
“The goal is to improve the safety and quality of imaging services,” Paidosh says, noting that through its family of businesses, UnitedHealth Group serves approximately 70 million individuals nationwide.
These goals are in line with what both the ACR and IAC work to accomplish.
“Participating in the process of accreditation provides imaging facilities, regardless of modality, an opportunity to conduct an extensive evaluation of every aspect of daily operation,” says IAC President Gary V. Heller, MD, associate director of the division of cardiology and director of the Nuclear Cardiology Laboratory at the Hartford Hospital in Connecticut. “This in-depth assessment, combined with a detailed peer review, is extremely beneficial to laboratories as they strive to improve the quality of care they are able to provide patients.”
Dana Hinesly is a contributing writer for Axis Imaging News. For more information, contact .
The Bill Box
By Cat Vasko
CARE Bill Introduced in House
On January 19, HR 583—the Consistency, Accuracy, Responsibility, and Excellence in Medical Imaging and Radiation Therapy bill (aka the CARE bill)—was introduced into the House of Representatives. Previously known as the Consumer Assurance of Radiologic Excellence bill, HR 583 was introduced by Representative Mike Doyle (D-Pa); it is co-sponsored by longtime supporter Representative Chip Pickering (R-Miss) and a bipartisan coalition that includes representatives Marsha Blackburn (R-Tenn) and Lois Capps (D-Calif).
The CARE bill would require people performing the technical components of medical imaging and radiation therapy to meet federal education and credentialing standards in order to participate in federal health programs, such as Medicare and Medicaid. The bill’s previous iteration was passed by the Senate in December 2006, but it did not make it through Congress prior to the session adjournment.
“We’re very pleased that the bill was introduced so early in the session,” Christine Lung, director of government relations for the American Society of Radiologic Technologists (ASRT), Albuquerque, NM, said in a statement. “The CARE bill came very close to passing last year, and this is the earliest it has ever been introduced into a session. We want to keep the momentum going. This is the fifth time the bill has been introduced into Congress, and each time, we get closer.”
The ASRT changed the bill’s name with this year’s introduction into Congress, Lung explained, because “the new name more accurately reflects the global nature of medical imaging, which now plays an important role in every area of medicine.”
Malpractice Bill Would Cap Damages Collected from Individual Providers
On January 10, Senator John Ensign (R-Nev) reintroduced medical malpractice legislation that he previously sponsored in the 109th Congress. The bill, S 243, would limit the malpractice damages collected from any one provider to $250,000, with a total possible cap of $750,000. Last year, the bill—which also would place caps on attorneys’ fees—invoked ire from both Democrats and trial lawyers, but garnered the support of the American Medical Association, which issued a release validating the cost-lowering effects of the Texas law after which S 243 was modeled.
“The AMA supports national legislation based on proven reforms, including a quarter-million dollar cap on noneconomic damages for physicians, that work to stabilize medical liability insurance premiums and preserve patients’ access to physicians,” the AMA’s release states. “[The bill is] based on reforms working in Texas to stop that state’s medical liability crisis. Texas enacted medical liability reforms with limits on noneconomic damages—and the new law works. Premiums are down, and physicians have flocked to the state, improving access to care for Texas patients.”
Bill to Create Bipartisan Commission to Help Sustain Medicare
On January 22, senators Dianne Feinstein (D-Calif) and Pete Domenici (R-NM) introduced a bill to establish a permanent, bipartisan commission to provide recommendations on Medicare’s long-term sustainability. Calling for a commission consisting of seven Democrats, seven Republicans, and one independent, the bill would require that recommendations be issued every 5 years. According to the two senators, Medicare and Social Security expenditures will account for 60% of the federal budget by 2016 if nothing is done to curb spending.
State of the States: What’s on the Slate?
January 2007 State of the State speeches provided a window into what might be coming this year in state health care legislation. In her January 22 speech, Governor Linda Lingle (R-Hawaii) called for “sensible medical malpractice reform based on the California model,” ensuring that patients “can recover for their actual damages, while putting reasonable limits on so-called noneconomic damages.” Lingle also proposed a “Good Samaritan” law prohibiting malpractice suits against physicians providing medical treatment without compensation, except in cases of severe negligence, and modifications to the process used to determine whether medical facilities can be built, so “local communities have the final say in determining which new medical facilities and services to support.”
Governor Matt Blunt (R-Mo) proposed a system called MO HealthNet, which would replace the current Medicaid system, allowing participants to choose their own health plan and paying physicians “for results, not just visits or tests.” Blunt also revealed that he has committed $20 million for a proposal to offset the price of insurance using federal, state, public, and private resources.
Governor Jim Gibbons (R-Nev) also addressed Medicaid reform, proposing an increase in Nevada Medicaid physician payments to match the most recent federal Medicare fee schedule—while holding physicians accountable for quality of care.
Cat Vasko is associate editor of Axis Imaging News. For more information, contact .
HealthHelp Certified by NCQA
HealthHelp, Houston, a national radiology benefit management company announced January 11 that it had received certification from the National Committee for Quality Assurance (NCQA), Washing-ton, DC, in utilization management. NCQA is an independent, not-for-profit organization dedicated to assessing the quality of US managed care plans.
NCQA certification is a voluntary review process and quality assessment program focused on consumer protection and customer service improvement. “Achieving organization certification from NCQA demonstrates that HealthHelp has the systems, processes, and personnel in place to conduct utilization management in accordance with the strictest quality standards,” NCQA President Margaret E. O’Kane said in a statement.
HealthHelp is known for innovative national radiology quality assurance programs as well as for its nationwide network of diagnostic imaging facilities. “HealthHelp’s NCQA certification in utilization management comes at the end of a busy and fruitful 2006,” said HealthHelp CEO Cherrill Farnsworth. “HealthHelp, like NCQA, is committed to protecting health care consumers and ensuring that they receive excellent care every time they seek medical care.”
For more information, visit www.healthchoices.org.
Illinois Attorney General Intervenes in MRI Kickback Lawsuit
On January 17, Lisa Madigan, the Illinois state attorney general (AG), intervened in a state lawsuit brought by imaging center operator John Donaldson, acting as a private citizen, against several radiology centers. The suit alleges that the centers disguised physician kickbacks via arcane MRI equipment “leasing agreements,” violating the Consumer Fraud and Deceptive Business Practices Act and the Insurance Claims Fraud Prevention Act, causing overutilization and ultimately burdening patients with escalating costs.
The suit, which is now in the AG’s hands, alleges that the defendant MRI centers—including MIDI LLC, Golf Diagnostic Imaging, Northwest Corporate Imaging, and Rand Imaging—set up a scheme wherein physicians bill insurers for MRI examinations that they did not perform and then split the payments among the MRI centers. Leasing agreements make it seem as if the physicians are renting the MRI centers to perform scans for patients.
“The use of these agreements has led to overutilization by physicians, which has a cost to society,” says Ruth Ramsey, MD, medical director of MRI of River North, Chicago. “I think that’s very clear. It increases the cost of services. It has resulted in unnecessary procedures. When you’re in a lease agreement, centers don’t need to compete, so they don’t need to have equipment that’s state of the art, they don’t have to maintain it, and they may shorten exams in order to increase their throughput.”
Ramsey has noted an impact in her market as a result of the now-scrutinized practice. “We’ve seen a decrease in referrals to our center,” she says. “Physicians are motivated by the economics of these agreements. For a variety of reasons, they’ve seen a decrease in income, and this was a method of increasing their income.”
The AG’s office is clear on its stance. “Illinois has a clear policy against kickbacks, and making payments to doctors for referral of patients is illegal, no matter how those payments are disguised,” Madigan said in a statement. “Our investigation revealed evidence showing that this practice occurs among doctors and radiology centers in Illinois. This is an illegal practice that must stop.”
Ramsey warns, however, that leasing agreements aren’t the only problem. “I think these agreements are certainly immoral, and I personally believe they should be illegal, but the in-office exception represents another loophole,” she notes. “This is explicitly allowed, but in my opinion, it’s completely wrong. Physicians should not be allowed to refer where they have an economic interest. It results in abuse of the patient and overutilization, which also makes the patient—and ultimately each and every one of us—suffer.”
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To read one radiologist’s opinion of the action in Illinois, visit “The Last Word.”
The case originally was filed in the Cook County Circuit Court and is now being handled by AG Assistant Bureau Chief David Adams and Assistant AG Janet Doyle of the Special Litigation Bureau.
Health Plans Ramp Up RBM Programs
Health plans are developing radiology benefit management (RBM) programs in the hopes of curbing overutilization of high-cost procedures like MRI, CT, PET, and nuclear cardiology studies. The newest health plans to jump on the RBM bandwagon are Blue Cross and Blue Shield of North Carolina, Durham, NC, and HealthPartners Inc, Bloomington, Minn, according to an article in Managed Care Week (MCW). BCBS North Carolina will require physicians to obtain preauthorization before ordering imaging services, and HealthPartners will require prenotification.
Dozens of health plans have introduced similar programs in recent years in response to the escalating cost of imaging services, which cost 20% more each year, according to some estimates. Bob LaGalia, CFO of National Imaging Associates (NIA), Phoenix, told MCW that his company’s RBMs could reduce this amount by 2% or 3%. NIA CEO Eric Reimer added, “We’re seeing a movement to total cost management. If you look at volume but don’t look at unit-cost dollars, they kind of bubble back up.”
HealthPartners will enact the program via vendor American Imaging Management Inc, Deerfield, Ill; the health plan will attempt to discourage referring physicians from ordering unnecessary scans, but will not refuse to authorize or pay for these studies. This setup is relatively typical; most RBM programs operate similarly, requiring physicians or office staff to notify the program vendor of any scans ordered. Those that send up red flags are reviewed by vendor staff, who recommend alternate courses of treatment as necessary.
BCBS North Carolina will take it a step further by denying coverage for studies deemed unnecessary. Debra MacClennan, vice president of member health partnerships at BCBS North Carolina, told MCW that her company initiated a similar program in 2002 that merely tracked utilization without enforcing ordering regulations. The insurer noted a 160% increase in MRI and CT costs between 1999 and 2004, and saw utilization of outpatient diagnostic imaging services rise 21% between 2003 and 2005, with total costs increasing 18% to 25% each year.
Insurers are working to make it easier for physicians to meet RBM requirements; many RBM vendors have created online systems to ease the administrative burden on physicians, allowing office staff to use a Web-based platform to obtain approval for studies. LaGalia told MCW that at one plan where NIA has initiated online service, it is used by more than 60% of physicians. HealthPartners hopes to implement a similar system, sparing physicians and their staff the hassle of the telephone-based notification process.
Maximize Mammography Reimbursement
Rigorous billing and coding are mandatory
Many hospitals and practices dismiss mammography as a loss leader; however, with close attention to billing and collections, providers can maximize breast imaging revenue, according to Lawrence W. Bassett, MD, professor and director of the Iris Cantor Breast Center at the University of California, Los Angeles, who presented at the 26th Annual Breast Imaging Conference, held September 28–30, 2006, in Las Vegas. Because of the slim margins, it is more important with mammography than any other modality to institute rigorous billing and coding practices to guard against denials and the cost of resubmitting a bill.
The basics are that for every examination performed, there must be an ICD-9 code representing an appropriate clinical indication for the exam as well as an appropriate CPT code, which indicates what kind of examination was performed. Mammography has just three CPT codes:
- CPT 76090: unilateral diagnostic mammogram;
- CPT 76091: bilateral diagnostic mammogram; and
- CPT 76092: screening mammogram.
But screening and diagnostic mammography have different ICD-9 codes. The V codes are used for screening: V76.11 is used to indicate a screening examination for a high-risk patient; and V76.12 is used to indicate screening for breast cancer, not a high-risk patient. Examples of ICD-9 codes for diagnostic examinations include 174 (malignant neoplasm) and 793 (nonspecific abnormal findings on radiological or other breast examinations). Additional codes for diagnostic mammograms and ultrasound are 611.72 (lump or mass), 611.71 (pain), 610.0 (cyst), 611.3 (fat necrosis), and 612 (benign neoplasm). Problems arise when there is a disconnect between the ICD-9 and the CPT—in other words, most payors will not accept “asymptomatic woman with no risk factors” as justification for a diagnostic mammogram.
Providing a history of reimbursement, Bassett reviewed the landmark Acts—including the creation of the Prospective Payment System in 1983, the 1992 establishment of the resource-based relative value system and the Medicare Physician Fee Schedule (MPFS), the 2000 Hospital Outpatient Prospective Payment System and its ambulatory payment classifications, and the Balanced Budget Act of 1997, the last of which legislated office and hospital rates for screening and diagnostic mammography, making it unique among all medical procedures in that regard. The Benefits Improvement and Protection Act of 2000 placed screening mammography under MPFS rules as of 2002, liberating mammography reimbursement from congressional captivity and nearly a decade of no increases. In 2002, the Medicare, Medicaid, & State Child Health Insurance Program increased reimbursement for full-field digital mammography units and computer-aided detection technologies, a somewhat controversial decision, as it was made well in advance of the results of the DMIST trials.
Watch for the following specific reasons for denials in mammography reimbursement, Bassett advised:
- Under the age of 35, there is no reimbursement for mammography screening.
- Between ages 35 and 39, patients may have one baseline mammogram.
- From age 40 on, Medicare and most other insurers will pay for only one screening per year; at least 11 months must have passed following the month of the previous screening mammogram.
- A facility has failed to obtain a signed Advance Beneficiary Notice (ABN) from the patient, even if the physician believes she may not be reimbursed for the examination. If you do not receive the ABN and the patient is billed, the facility is liable for heavy fines.
- A physician’s prescription or referral is necessary for a diagnostic mammogram to be covered, but not a screening mammogram.
- Appropriate indications for a diagnostic mammogram include man or woman with signs of breast disease, a personal history of breast cancer, and/or a personal history of biopsy-proven benign disease.
- As of 2002, facilities can submit claims for both screening and diagnostic mammograms on the same day, but Medicare requires a GG Modifier be attached to the diagnostic mammogram code.
For imaging-guided biopsy, remember that the ICD-9 code is case specific, Bassett warned—for example, breast mass or calcifications. Also, two CPT codes must be used. One is for the technology used: either 19102 (imaging-guided core biopsy) or 19103 (Automated VAD). The other is for the image guidance: 76095 (stereotactic localization) or 76942 (ultrasound guidance for biopsy). Only one CPT code per lesion is allowed; the provider may not bill for each pass. It also is important that the radiologist’s report clearly state the indication and describe the technical aspects of the procedure in detail—the type of core, needle device, needle gauge, number of lesions sampled, locations, and a final impression, for instance.
Bassett offered the following tips to maximize reimbursement:
- Engage everyone—schedulers, receptionists, technologists, and radiologists—to ensure that the indication is an acceptable reason for the test.
- Schedulers are the key to obtaining correct information from referring offices to ensure that the ICD-9 is legitimate for the procedure.
- Implement user-friendly computer ordering programs designed to accept appropriate requests only.
- Develop an easy-to-use requisition form for referrers that includes a checklist of procedures and symptoms; the law mandates a faxed or signed referral for the performance of a diagnostic mammogram with the appropriate diagnosis ICD-9 code.
- Meet with referring physician staff on how to order examinations.
- Institute prior authorization procedures at the time of ordering.
- Be sure to have the patient fill out a form explaining why they are seeking medical attention.