A Claims-Based Method for Identification and Characterization of Practicing Interventional Radiologists.

PURPOSE: To propose a research method for identifying "practicing interventional radiologists" using 2 national claims data sets. MATERIALS AND METHODS: The 2015-2019 100% Medicare Part B data and 2015-2019 private insurance claims from Optum's Clinformatics Data Mart (CDM) database were used to rank-order radiologists' interventional radiology (IR)-related work as a percentage of total billed work relative value units (RVUs). Characteristics were analyzed at various threshold percentages. External validation used Medicare self-designated specialty with Society of Interventional Radiology (SIR) membership records; Youden index evaluated sensitivity and specificity. Multivariate logistic regression assessed practicing IR characteristics. RESULTS: In the Medicare data, above a 10% IR-related work threshold, only 23.8% of selected practicing interventional radiologists were designated as interventional radiologists; above 50% and 90% thresholds, this percentage increased to 42.0% and 47.5%, respectively. The mean percentage of IR-related work among practicing interventional radiologists was 45%, 84%, and 96% of total work RVUs for the 10%, 50%, and 90% thresholds, respectively. At these thresholds, the CDM practicing interventional radiologists included 21.2%, 35.2%, and 38.4% designated interventional radiologists, and evaluation and management services comprised relatively more total work RVUs. Practicing interventional radiologists were more likely to be males, metropolitan, and earlier in their careers than other radiologists at all thresholds. CONCLUSIONS: Most radiologists performing IR-related work are designated in claims data as diagnostic radiologists, indicating insufficiency of specialty designation for IR identification. The proposed method to identify practicing interventional radiologists by percent IR-related work effort could improve generalizability and comparability across claims-based IR studies.

Radiologists' Out-of-Network Billing Trends, 2007 to 2021.

PURPOSE: Given the financial hardships of surprise billing for patients, the aim of this study was to assess the degree to which radiologists effectively participate in commercial insurance networks by examining the trend in the share of radiologists' imaging claims that are out of network (OON). METHODS: A retrospective study over a 15-year period (2007-2021) was conducted using claims from Optum's deidentified Clinformatics Data Mart Database to assess the share of radiologists' imaging claims that are OON. Radiologists' annual OON rate was assessed overall as well as for claims associated with inpatient stays and emergency department (ED) visits. Rates were assessed for all imaging studies as well as by modality. Linear regression was conducted to assess OON rate time trends. RESULTS: From 2007 to 2021, 5,039,142 of radiologists' imaging claims (6.3%) were OON. This rate declined from 12.6% in 2007 to 1.1% in 2021. Over the study period, the OON rate was 5.0% during an inpatient stay and 2.1% on the same day as an ED visit that did not lead to an inpatient admission. The linear trend in the overall OON rate declined 0.74 percentage points annually (95% confidence interval [CI], -0.90 to -0.58 percentage points) over the study period. Likewise, the annual declines were 0.54 percentage points (95% CI, -0.71 to -0.36) and 0.26 percentage points (95% CI, -0.33 to -0.20 percentage points) for imaging claims associated with inpatient stays and ED visits, respectively. CONCLUSIONS: Radiologists' imaging claims that are OON has significantly declined from 2007 to a minimal level in 2021. This may indicate effective negotiations between radiologists and commercial payers and new state-level surprise billing laws.

Financial Viability of the No Surprises Act Independent Dispute Resolution Process: Radiology and Other Hospital-Based Specialties.

BACKGROUND. The federal No Surprises Act (NSA), designed to eliminate surprise medical billing for out-of-network (OON) care for circumstances beyond patients' control, established the independent dispute resolution (IDR) process to settle clinician-payer payment disputes for OON care. OBJECTIVE. The purpose of our study was to assess the fraction of OON claims for which radiologists and other hospital-based specialists can expect to at least break even when challenging payer-determined payments through the NSA IDR process, as a measure of the process's financial viability. METHODS. This retrospective study extracted claims from a national commercial database (Optum's deidentified Clinformatics Data Mart) for hospital-based specialties occurring on the same day as in-network emergency department (ED) visits or inpatient stays from January 2017 to December 2021. OON claims were identified. OON claims batching was simulated using IDR rules. Maximum potential recovered payments from the IDR process were estimated as the difference between the charges and the allowed amount. The percentages of claims for which the maximum potential payment and one-quarter of this amount (a more realistic payment recovery estimate) would exceed IDR fees were determined, using US$150 and US$450 fee thresholds to approximate the range of final 2024 IDR fees. These values represented the percentage of OON claims that would be financially viable candidates for IDR submission. RESULTS. Among 76,221,264 claims for hospital-based specialties associated with in-network ED visits or inpatient stays, 1,482,973 (1.9%) were OON. The maximum potential payment exceeded fee thresholds of US$150 and US$450 for 55.0% and 32.1%, respectively, of batched OON claims for radiologists and 76.8% and 61.3% of batched OON claims for all other hospital-based specialties combined. At payment of one-quarter of that amount, these values were 26.9% and 10.6%, respectively, for radiologists and 56.6% and 38.4% for all other hospital-based specialties combined. CONCLUSION. The IDR process would be financially unviable for a substantial fraction of OON claims for hospital-based specialists (more so for radiology than for other such specialties). CLINICAL IMPACT. Although the NSA enacted important patient protections, IDR fees limit clinicians' opportunities to dispute payer-determined payments and potentially undermine their bargaining power in contract negotiations. Therefore, IDR rulemaking may negatively impact patient access to in-network care.