Radiology Administrator's Compliance & Reimbursement Insider, December 2004

Once you gather your data, strategically review their outcomes to help you negotiate higher rates from payers. Start with these queries:

According to the scientists and physicians at Aurora Imaging in North Andover, MA, a better sweet spot exists-at least in the area of breast imaging.

Their system's magnet, patient table, radiofrequency (RF), and gradient coils are specifically designed for breast imaging, including uniform simultaneous imaging of both breasts.

Additionally, the uniquely contoured examination table allows the patient's breasts to be suspended away from the chest wall, without compression.

Logic says such suspension would, indeed, provide a better breast image.

With help from his colleagues, Steven Harms, MD, director of imaging research in the University of Arkansas department of radiology in Little Rock developed RODEO (rotating delivery of excitation off resonance) as a proprietary pulse sequence that provides "robust, fat-suppressed magnetization transfer contrast in an efficient high-resolution MRI acquisition."

Magnetization transfer contrast is used to reduce signals from normal ductal tissue and avoid false-positive enhancement from benign lesions and dense fibroglandular tissue common in young women.

Applying the RODEO fat-suppression technique in breast MRI after contrast injection (gadolinium) enables physicians to focus on diseases affecting ductal or glandular tissue without the distraction of fat tissue.

Such contrast avoids what Harms calls the "snowman in a snowstorm" effect in which fat and cancer are both bright on the MRI. Typically, fat suppression is not possible when both breasts are imaged and is not fast enough to generate dynamic curves.

Insider source
Steven Harms, MD, director of imaging research in the University of Arkansas department of radiology in Little Rock.

Breast magnetic resonance imaging (MRI) reimburses well-it can be compared to brain MRI with contrast. You may consider the procedure medically necessary under these seven conditions:

Prompt-payment laws were enacted by Congress as a result of public complaints about insurers' disregard for standard payment terms across the marketplace.

Physician practices and hospitals often find that their clean claims sit in a payer queue or are simply held in accounts payable until the money is ready for release. Such arbitrary decisions regarding payment terms by payers can have devastating effects on cash flow for small physician practices.

Placing the issue on legislators' radar screens and crafting bills to stem payer abuses has had a beneficial effect, but the resulting statutes are so riddled with loopholes that the net effect has hardly been a total fix.

Many physicians either aren't aware of their rights under the laws or are uncertain how to access the statute to claim their overdue money. Further, in some states, payer contracts supersede the prompt-pay laws, so physicians may not benefit from some of their provisions.

Members of the healthcare community must take it upon themselves to police their payers compliance with prompt pay rules.

This requires coordination within the billing department and use of technology to monitor the actual time from submission of the clean claim to remittance. If a practice or hospital wants to use the legislation to demand payment, it must be able to document abuse by their payer. Most states will not intervene without quantitative data of the outstanding receivables.

In April, the U.S. Department of Labor (DOL) released new regulations governing overtime pay designed to make it easier for employers to determine which employees will be exempt from overtime pay and who is entitled to receive it.

The regulations appear to provide several much-needed updates and clarifications to exemptions from the Fair Labor Standards Act (FLSA).

These improvements will likely limit lawsuits and could ease recruitment. However, it will require an increase in payroll budgets for many institutions.

The previous standards for determining whether a worker was eligible for overtime left employers in a quagmire. Exemption status was not always clear, and court rulings on overtime have been difficult to predict.

In this environment, there have been a plethora of lawsuits and class-action judgments on the FLSA have reached as high as $90 million.

The new regulations do not represent a major policy shift. However, they do provide some clarity to the numerous grey areas that have developed in the past 50 years.

For example, the regulations clear up the question of "discretion and independent judgment." Previously, exempt employees "used discretion and independent judgment in their position," according to the description. There was no description of how to measure this critical variable.

The new regulations, however, provide explicit guidance, incorporating case law and the experience of DOL caseworkers to give employers a better indicator of which occupations involve sufficient discretion to qualify as exempt.

One large substantive change expands overtime coverage for some small department supervisors. Until now, workers making as little as $8,060 per year-below minimum wage-could be considered "white collar." The new regulations raise that minimum standard to $23,660. This change will be a windfall to low-level supervisors, and many will now automatically receive overtime pay.

Particularly helpful for healthcare employers are the learned professional examples and explanations that illustrate how to apply the exemption, including occupations that are now classified as exempt from overtime, such as

 registered or certified medical technologists who have four years of college and coursework approved by the Council of Medical Education of the American Medical Association. Each state has different requirements for licensing or certification of technologists that may require an academic degree. Check each state's regulations when reviewing these exemptions.

 registered nurses who are registered by the appropriate state examining board (same as the current regulations; licensed practical nurses generally do not qualify for the learned professional exemption).

 Physician assistants who have completed four academic years of study approved by a designated credentialing body.

Make sure your technologists' documentation is properly filed and secured in the patient chart-not just randomly stuffed in, or worse, scribbled on a film jacket. A tech's notes provide an essential portion of the roadmap to the radiologist's decision-making, explains Atlanta-based radiology compliance expert Jackie Miller. Although the radiologist should dictate the salient aspects of the tech's notes into his or her interpretive report, that doesn't always happen, she says. For example, your techs may often take a patient history and ask about allergies or occupational exposure to metal.

The answers to these questions will determine certain medical decisions, such as whether to use nonionic contrast media or perform an x-ray of the orbit before a magnetic resonance imaging test. A tech's notes often reveal whether the patient can tolerate certain tests-for example, a bending view of a limb may not be possible in an arthritic patient.

Having well-organized tech notes readily available can help if you're ever audited, says Miller. Otherwise, if the radiologist doesn't mention the tech's findings in his or her report, you'll need to produce the tech's notes to justify your medical decision-making and coding selections. It's important to keep the tech's notes with the main body of the patient chart and arranged chronologically and seamlessly with the other entries.

Jackie Miller, Per-Se Technologies Consulting Group, 2840 Mount Wilkinson Pkwy., Atlanta, GA 30339; jackie.miller@per-se.com.

Signs of success are cropping up in the longstanding struggle to make mammography profitable. Although the field is still largely a loss leader, reimbursement rates have increased in the past few years, advanced technology and equipment are spurring more efficient practice, and improved marketing strategies are boosting bottom lines.

"As long as we're not losing money per patient, which we were at one point, we don't have to turn anyone away," says Wende Logan-Young, MD, director of the Elizabeth Wende Breast Clinic in Rochester, NY, which performs about 75,000 mammograms a year. "We're struggling along," she adds, noting her center's average reimbursement is about $75 per mammogram. "But God knows what will happen when they cut back Medicare in 2005 for 2006. Everybody's on edge."

William Poller, MD, director of radiology at Allegheny General Hospital in Pittsburgh, says technology advances, especially computer-aided detection (CAD) "can put a facility over the top" in profitability. "If you own your own imaging center, MR [magnetic resonance] and CAD will be of great value, financially and otherwise."

Phil Evans, MD, director of the University of Texas Southwestern Center for Breast Care in Dallas, whose 1998 study established the basis for FDA approval of CAD for screenings, says "there's a wealth of data proving that CAD can find cancers otherwise undetected."

Evans suggests the following strategy for stressing the value of CAD to payers:

Show that CAD is part of treatment, not an add-on. Both Evans and Poller say nearly all their CAD screenings are now reimbursed by insurance. In 2002, when a major insurer in Texas declined to pay for CAD, "we talked to them, presented the data that CAD was effective, and they paid," Evans says.

This may take persistence. Getting paid for CAD currently is "the biggest challenge for the financial person," says Melody Mulaik, president of Coding Strategies in Atlanta. "Some insurers say it is not medically necessary, it's an add-on, or nice to have, and the facility has to swallow the cost."

Wende Logan-Young, MD, director of the Elizabeth Wende Breast Clinic in Rochester, NY.

Melody Mulaik, president of Coding Strategies in Atlanta. E-mail Mulaik at Melody.
Mulaik@CodingStrategies.com.

William Poller, MD, director of radiology at Allegheny General Hospital in Pittsburgh.

-Recruit retirees and consider subsidizing fellows in an effort to bolster your practice, says James Paul Borgstede, MD, who manages a 17-provider radiology practice in Colorado Springs, CO. Colorado Springs Radiologists hired eight of its 17 full-time physicians during the past five years, Borgstede says.
The group's growth-a 12.5% increase in exams per year-and Borgstede's decision to offer round-the-clock in-house calls paved the way for the staffing boom.

-Subsidize two radiologists through fellowships. "Fellows need money to stay in training, plus this costs us nothing," Borgstede says. "We take the money from the fellows plus the dollars they earn in the first year and then distribute it over a two-year period."

-Hire early for future needs. Borgstede's practice has one more full-timer than it needs, "and that should level out," he says. "But most practices wait until they're one [full-time equivalent] down, and then they hire. I don't think that model works."

-Share on-call shifts and use physician extenders. Also look into teleradiology, Borgstede says-but be prepared for Medicare problems.

-Try exceeding the cap and hiring more residents for your practice to lure more women-one of the three subspecialties with the highest demand-to fill your mammography openings. "Consider it; our practice does," says Denver-based radiologist Carol Rumack, MD.

"Medicare caps reimbursement, but our hospital is willing to exceed the cap" and seek other sources of payment, she says. Paying a resident's salary costs less than paying most other physicians, such as faculty, says Rumack.