No Surprises Act: Legal Challenges and Implications for Radiology.

When the word "surprise" is used as a noun, it generally describes an unexpected event. When "surprise" is used in conjunction with "billing", it conjures up images with which even the most hardened backroom medical administrator can empathize. One's first reaction is likely patient based, that a person received medical services from a health care provider or facility that are larger than anticipated in-network charges. As a result, the bill for services incorporates that, no-doubt unpleasant, surprise. The whole truth is understandably more complex. Radiology groups contract with insurance companies who for their own reasons, might have historically preferred progressively narrower networks. Nonetheless, these contracts allow providers the opportunity to negotiate reasonable payments for services rendered. Events have changed the historic dynamic between providers and insurance companies.

The time has arrived for national reimbursement of screening CT colonography.

OBJECTIVE: CT colonography (CTC) has been fully validated as an accurate screening test for colorectal carcinoma and is being disseminated globally. There is an abundance of new literature addressing the prior concerns of the U.S. Preventive Services Task Force and the Centers for Medicare & Medicaid Services. Specific areas related to radiation dose, extracolonic findings, and generalizability of CTC to senior patients are discussed. CONCLUSION: The time has arrived for national reimbursement of CTC in the United States.

Strategies for managing imaging utilization.

Imaging represents a substantial and growing portion of the costs of American health care. When performed correctly and for the right reasons, medical imaging facilitates quality medical care that brings value to both patients and payers. When used incorrectly because of inappropriate economic incentives, unnecessary patient demands, or provider concerns for medical-legal risk, imaging costs can increase without increasing diagnostic yields. A number of methods have been tried to manage imaging utilization and achieve the best medical outcomes for patients without incurring unnecessary costs. The best method should combine a prospective approach; be transparent, evidence based, and unobtrusive to the doctor-patient relationship and provide for education and continuous quality improvement. Combining the proper utilization of imaging and its inherent cost reduction, with improved quality through credentialing and accreditation, achieves the highest value and simultaneous best outcomes for patients.

ACR Colon Cancer Committee white paper: status of CT colonography 2009.

PURPOSE: To review the current status and rationale of the updated ACR practice guidelines for CT colonography (CTC). METHODS: Clinical validation trials in both the United States and Europe are reviewed. Key technical aspects of the CTC examination are emphasized, including low-dose protocols, proper insufflation, and bowel preparation. Important issues of implementation are discussed, including training and certification, definition of the target lesion, reporting of colonic and extracolonic findings, quality metrics, reimbursement, and cost-effectiveness. RESULTS: Successful validation trials in screening cohorts both in the United States with ACRIN and in Germany demonstrated sensitivity > or = 90% for patients with polyps >10 mm. Proper technique is critical, including low-dose techniques in screening cohorts, with an upper limit of the CT dose index by volume of 12.5 mGy per examination. Training new readers includes the requirement of interactive workstation training with 2-D and 3-D image display techniques. The target lesion is defined as a polyp > or = 6 mm, consistent with the American Cancer Society joint guidelines. Five quality metrics have been defined for CTC, with pilot data entered. Although the CMS national noncoverage decision in May 2009 was a disappointment, multiple third-party payers are reimbursing for screening CTC. Cost-effective modeling has shown CTC to be a dominant strategy, including in a Medicare cohort. CONCLUSION: Supported by third-party payer reimbursement for screening, CTC will continue to further transition into community practice and can provide an important adjunctive examination for colorectal screening.

The current status of local medicare payment policy: how specialty societies can influence local coverage determinations.

The Medicare Fee-for-Service Program is in the midst of numerous administrative and regulatory changes that may affect the way local Medicare payment policy is implemented. These changes involve redefining the contractors' jurisdictions, competitive bidding for the contractor selection process, combining the administration of Part A and Part B services, and error rate auditing. In addition, the roles of the Contractor Medical Directors and Contractor Advisory Committees are yet to be defined, and the future of the existing advisory process, while currently unchanged, remains uncertain. Most likely, the majority of coverage decisions will continue to be made at the local level; however, the Centers for Medicare & Medicaid Services (CMS) has begun to increase its use of Technology Assessments and National Coverage Determinations for new technology and has developed a new payment category for coverage of new technology: Coverage with Evidence Development. Specialty societies continue to have the ability to exert influence on the coverage process. The American College of Radiology (ACR) monitors the activity of the local contractors and assists local physicians through the ACR Carrier Advisory Committee Network. The ACR has used a combination of clinical and economic experts to develop model Local Coverage Determinations for use by the local contractors, and some of these model policies have been developed in conjunction with other specialty societies, which bolsters their effectiveness. The changing administrative environment presents challenges and opportunities for specialty societies to influence local CMS payment policy.

National and local trends in CT colonography reimbursement: past, present, and future.

Computed tomographic colonography (CTC) was first introduced in the mid-1990s as a minimally invasive technology for colorectal cancer screening. Given its potential to significantly change colorectal cancer screening practices in the United States, it has attracted widespread multidisciplinary interest among radiologists, gastroenterologists, colorectal surgeons, and primary care physicians. Because of its potential for widespread utilization and the potential associated costs, it has also attracted much scrutiny from payers. The authors discuss the coding and reimbursement history of CTC, outline strategies for obtaining local coverage for CTC, and attempt to outline some of the possible future influences on CTC reimbursement.

The ACR Managed Care Committee: focusing private payers on radiology issues.

The ACR Managed Care/Private Payer Relations Committee is an important committee of the ACR Commission on Economics. This report reviews the committee's mission, structure, and processes and some of its current recommendations to ACR membership. The development of and participation in radiology advisory committees is a vital strategy in this process. Separating professional and technical charges, rather than submitting global charges, will help preserve radiology's professional integrity in the future. The Imaging Provider Report Card (IPRC) will allow radiology to define practice quality and performance in an era of pay-for-performance reimbursement. The IPRC also provides an external blueprint on what each practice needs to do to improve itself. American College of Radiology accreditation plays a key role in certifying radiology's quality to both payers and patients. Sound business management, group governance, and business size are also important elements of professional practice success. Working together through the ACR promotes the integrity of our profession and the quality of care patients want and deserve.

Pay for performance in radiology: ACR white paper.

During the next few years, some portion of physician reimbursement will be increasingly based on the quality and efficiency of service, a practice commonly referred to as pay for performance (P4P). Performance benchmarks are the discrete parameters of structure, process, or outcome metrics whose attainment defines good quality care. Private payers are already rewarding primary care physicians for practices that adhere to quality standards, are efficient, involve information technology, and result in high patient satisfaction. The Centers for Medicare and Medicaid Services will have completed the development of performance measures to be used in Medicare payment strategies for all specialties by the end of 2006 and anticipates phasing in the program fully by 2008. This article describes P4P, its importance to the ACR, the organizations involved in developing it, the ACR's activities to date, and the steps the ACR must take to ensure that radiologists are remunerated fairly as physician payment becomes based, in part, on performance.

Medicare reimbursement for physician services: the current status of local payment policy.

Keeping up with the technical and academic advances in medicine of the past 2 decades has made studying the US government's physician reimbursement system a low priority for most physicians. However, in the current environment of declining physician reimbursement and increasing frequency of compliance audits by Medicare, it is important for all physicians to have a basic understanding of the Medicare payment process. A major component of the physician payment system occurs at the local level. Through local coverage determinations, state Medicare contractors make more than 90% of all Medicare coverage decisions. Federal law requires Medicare contractors to seek physician input into their coverage decision process through contractor advisory committees, and through these committees, physicians can have significant influence over the coverage decision process. Once local contractors have made their coverage decisions, the covered indications for a procedure or treatment are published for the provider community. At that point, it becomes the responsibility of physicians to know the covered indications for certain services, because contractors will deny claims for services that are not linked to covered indications. This review focuses on the basics of the local Medicare payment process, with emphasis on the development of local coverage decisions by contractors. This understanding will allow physicians to positively influence the local reimbursement process.