Radiology Administrator's Compliance & Reimbursement Insider, April 2007

If no intention of physically performing the tasks or being in the building exists, ask if payment of rent between one party and another is appropriate at all.

If, for example, a rental agreement shows payments of values higher than other similar-sized facilities in similar areas, expect scrutiny from the OIG, private payers, or, as in the Illinois case, other competitors.

"Generally, physicians must have regularly scheduled rental times and must pay fair market value for the space, regardless of whether they actually use the machine or not," says Berlin. Similarly, subleases that cost more per square foot than the primary lease could also raise eyebrows. Rental rates need to reflect an advanced, fixed agreement, the OIG says.

Both parties must understand the set, per-hour rate, and schedule of rental. "As needed" use agreements offer questionable opportunities for legitimate increases in patient and procedure volumes.

Rentals that include referral fees, those that base rental amounts on the value of the referrals, or agreements that change more than annually also raise suspicion, the 2000 report says. In addition, expect scrutiny on any rentals conditioned on payments from federal healthcare programs.

Watch for agreements where suppliers' rental time exceeds actual needs. Document any prorating and update the agreement as necessary. The apportionment of shared spaces must be proportional to the number of additional lessees and the amount of time each spends using the office.

For example, if an ultrasound supplier's business requires only one exam room four hours per week, but it pays rent for eight hours per week, it may indicate kickbacks or fraud.

Rent may consist of three portions: exclusive office space, interior office common space, and building common space.

Use the following equation: Number of rooms multiplied by number of hours and number of uses per week, divided by the total number of rooms, hours, and times per week equals the supplier's total annual rent for exclusive space.

Caution required when crafting agreements

Many situations may make lease agreements necessary, but experts say exercise caution and careful analysis of the agreement prior to signing any papers.

"I get referrals the old fashioned way by offering quality service rather than financial incentives," says Berlin. "If someone were to say that I'd get more money if I sent my patients down the street, I'd question that arrangement. Everyone should. It just doesn't pass the sniff test. "

Gosfield agrees. "Ask yourself if you could defend the agreement on the front page of the local paper," she says. "If the answer is no, then you don't want to be involved in it."

Insider sources

Leonard Berlin, MD, director of radiology, Rush North Shore Medical Center, 9600 Gross Point Road, Skokie, IL 60076, 847/933-6111; Leonard_Berlin@rsh.net.

Alice G. Gosfield, attorney, Gosfield & Associates, PC, 2309 Delancey Pl. , Philadelphia, PA 19103, 215/735-2384; Agosfield@gosfield.com.

Michael F. Schaff, Esq. , attorney, Wilentz, Goldman & Spitzer, 90 Woodbridge Center Dr. , Suite 900, Box 10, Woodbridge, NJ 07095-095, 732/855-6047; mschaff@wilentz.com.

Kickback repercussions

Aside from the obvious ethical implications, kickbacks cause a number of problems. According to the federal anti-kickback statute, Section 1128B(b) of the Social Security Act, kickbacks

The Social Security Act prohibits knowingly and willfully soliciting, receiving, offering, or paying anything of value to induce referrals of items or services payable by a federal healthcare program. Both parties to an impermissible kickback transaction are liable, according to the law.

Violation of the statute constitutes a felony punishable by a maximum fine of $25,000, imprisonment up to five years, or both. The Office of Inspector General may also initiate administrative proceedings to exclude persons from federal healthcare programs or to impose civil money penalties for fraud, kickbacks, and other prohibited activities under Sections 1128(b)(7) and 1128A(a)(7).

Illinois case alleges kickback scheme

The Illinois attorney general (AG) in January joined a lawsuit against 11 imaging centers, charging filing of false claims, accepting illegal kickbacks, and bilking the government healthcare programs out of reimbursement dollars.

The original plaintiff in the case, whistleblower John Donaldson, filed suit in February 2006, according to court documents.

Donaldson and the AG's suit suggests that the MRI center operators submitted false claims at excessive rates to allow for the payment of an unlawful kickback to referring physicians who performed none of the billed services.

The court documents state that physicians referred patients to one of the named defendants, and that the defendant rendered the MRI scan.

The referring physicians then billed/invoiced the patient and the insurer under the physician's medical provider number for the defendant's work and collected the payment before dividing payment with the MRI center for the purported lease. "The purported lease agreement is a subterfuge utilized to cloak and hide the kickback for the referral," the suit states.

The suit seeks

The AG sealed the suit for 11 months while it investigated the case, finally concluding that the lease agreements were designed to disguise their true nature, according to court documents.

The case has not yet been heard.

Step-by-step

Resolve privileging conflicts between cards and rads

Editor's note: This is the fourth in a series about approaches to the cardiology-radiology debate over professional ownership of heart imaging techniques and reimbursement.

Cardiac imaging represents such a hot button issue for many facilities-from hospitals, to freestanding imaging, to independent cardiology and radiology practices. Cardiology-radiology turf battles can be extremely explosive, emotional, and destructive within an institution, so it's important to have a mechanism for addressing these privileging disputes when they arise at your facility.

Everyone knows the intensity of cardiology-radiology turf battles has increased in frequency and ferocity across the country in recent years, said Todd Sagin, MD, JD, vice president and national medical director of The Greeley Company, a division of HCPro, Inc. , in Marblehead, MA. Sagin spoke during the December 21, 2006, HCPro audioconference "The 64-Slice CT Scanner: The latest battleground in specialty turf disputes" (www.hcmarketplace.com/prod-4874.html).

Facilities can mitigate the conflict over control of cardiac imaging procedures through staff credentialing and privileging determinations. To understand this process, begin with the following four steps of credentialing and privileging:

1. Establish policies and procedures (e. g. , criteria)

2. Gather information

3. Assess and recommend

4. Review and grant

Identify existing policies

At the first intimation of any turf disputes, pull your hospital's policies for credentialing information to ensure that everyone understands the parameters for dealing with the issue, Sagin said. The criteria for establishing new credentialing and privileging standards shows all of the parties involved how to proceed.

Once you've identified the appropriate policies and procedures, determine whether the facility established a moratorium on processing any new privilege requests for emerging technology (e. g. , those for 64-slice CT scanners). Most policies do hold new requests until they create a policy specific for that modality.

But moratoriums must contain a definitive end point. That way, physicians-either radiologists or cardiologists-won't bypass the process simply out of frustration. A facility's credentialing development policies should also include clear guidelines for how long the moratorium lasts. Sagin suggested 60-90 days as a good general gauge.

"That's enough time for the facility to gather additional information and form a panel for discussion," he said.

Gather data

When gathering information, Sagin suggested that hospitals, as well as those involved in the cardiac imaging credentialing dispute, should examine the entire "universe of data out there to ensure that you make an informed decision. "

That means gathering credentialing information from other hospitals, specialty societies, literature, Credentialing Resource Center white papers, and the Web (e. g. , www.credentialinfo.com).

Determine what other hospitals of similar size and demographics in your region have established as criteria, said Sagin. Examine what involved specialty associations, in this case the American College of Radiology and American College of Cardiology, say about competency determinations for the specific modality and exam. Developing a competency in a particular area generally means performing the exam several times in a learning setting and providing evidence supporting that when you performed the scans, you performed them well.

Take some time to look at the proliferation of literature examining evidenced-based data for cardiac imaging. Look for information that correlates privileging data to outcomes to determine what effect such measures have.

If you're the radiology director of a large hospital bringing the turf issue to the credentialing committee, expect the group to push back much of this work onto your plate. If this is the case, take some wise advice and come to the committee prepared ahead of time. But also expect additional investigations from the credentialing committee for you and your staff.

"It doesn't all fall to a committee or to the medical staff office," said Sagin.

Develop the task force

With recommendations from cardiology and radiology department experts in hand, the credentialing committee can move forward.

"If everyone agrees [on a set of credentialing criteria], that's great-you don't have a dilemma anymore," Sagin said. "But if they don't agree-and that's more likely going to be the case-be ready to go back to your policy and take the next steps. "

At this point, with a plethora of information in hand and tensions still running high, look for the credentialing committee to appoint a task force that may or may not include leaders from the cardiology or radiology departments.

"You want some parties not involved in the turf battle to sit on the task force committee," said Sagin.

Hospital policies often make it clear that establishing privileging criteria "is not the domain of particular departments or specialties," Sagin said. "Just because they have expertise in an area does not give them the authority to establish privileging criteria. "

That doesn't mean radiology administrators can't offer their services to the task force.

Sagin recommended that the task force pull specialties in for testimony and evidence when not using such experts as task force members.

The task force mainly needs to make recommendations for cardiac imaging credentialing criteria back to the hospital's credentialing committee. It remains up to that group to finalize the recommendations and set parameters for who ultimately performs cardiac imaging scans and interpretations.

"As much as possible, participants should work within the framework of the results of the task force's research," Sagin said.

Take final steps

Before moving on to implementation, the credentialing committee must review the proposed criteria, vote on it, and refer the issue to the executive committee. If it the new credentialing and privileging criteria receive approval, then apply the criteria and consider your facility at least part of the way down the path to conflict resolution.

Insider source

Todd Sagin, MD, JD, vice president and national medical director of The Greeley Company, 200 Hoods Lane, Marblehead, MA, 01945, 781-639-1872; tsagin@greeley.com.

Coding corner

Make it about the money

Show physicians fiscal impact of proper coding and documentation to ensure buy in

Editor's note: This article is the second in a series about dealing with doctors to ensure compliant orders and documentation.

Poor physician documentation practices stem from more than mere lethargy. A variety of root causes-from lack of awareness to absence of documentation education-helps to aggravate the ongoing difficulties.

As stated in last month's issue, discuss appropriate documentation techniques with both radiologists and referring physicians in a professional manner. During your meeting, address the fiscal implications associated with appropriate documentation. Remind physicians that payers closely monitor utilization patterns for diagnostic radiology services. Physician's orders or documentation may unduly subject them, or the facility, to unwarranted scrutiny.

Further, if the facility sees decreased reimbursement due to improper documentation for specific services, it may need to eliminate or reduce those services. And that, says Stacy Gregory, RCC, CPC, president of Gregory Medical Consulting Services in Tacoma, WA, hurts everyone involved.

"Money talks," adds Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president of Southeast Radiology Management in Stuart, FL. "Yes, there's a liability issue associated with appropriate documentation. But if you show physicians the financials, you'll have their allegiance. " When meeting with physicians, come armed with facts and figures to illustrate the importance of this topic. Bring audit information and show them how much money reporting mistakes cost.

When your meeting ends, do not expect your physician to expresses complete agreement with your documentation and coding needs. Keep your guard up and take the following steps to preserve their involvement with the documentation, coding, and billing process:

Insider sources

Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president, Southeast Radiology Management, 512 SW St. Lucie Crescent, Stuart, FL 34994, 772/600-0324, stacie@southeastrad.com; www.seradmgt.com.

Stacy Gregory, RCC, CPC, president, Gregory Medical Consulting Services, 2661 N. Pearl St. #364, Tacoma, WA 98407, 253/566-2494; stacy@gregorymedicalconsulting.com.

Overread essentials: It's not just a turf war trouble

The specifics of the situation don't matter all that much. Whether radiologists perform overreads for cardiologists' cardiac computed tomographic angiography exam or a senior radiologist overreads a junior radiologist's exam-be careful about compliance and billing issues related to overreads. If a facility tries to bill for both sets of reads, it could end up in hot water.

Be aware of the following consequences and take precautions to avoid overread trouble and false-claim litigations.

Fraudulent overreads

Sometimes, facilities don't see anything wrong with this practice-physicians read the image twice, so reimbursement should match-but payers do not see it quite the same way.

In fact, under Medicare rules, overreads receive reimbursement only if the initial interpretation is equivocal, or if the interpreting radiologist requests a colleague's assistance in making a diagnosis. If there's no medical reason for completing an overread, there's no legal way to submit a claim for reimbursement for the overread.

Some practices get careless because they think that if they get caught, they'll just have to pay back the insurer for any overread it disallows. But the consequences of getting into trouble with an insurer over billing improperly for overreads can be far-reaching and devastating to a practice. They include the following:

1. Paybacks. If you're lucky, the insurer may only request that you repay it for overreads completed for reimbursement purposes, plus the insurer's costs or an administrative penalty.

More likely, however, the insurer will demand that you repay it for every overread it paid for-even those that may have been medically necessary. If even some overreads missed the medically necessary test, the insurer often shifts the burden of proof back onto the practice. Under such conditions, expect to go back through your records to prove which overreads were appropriate.

2. Contract termination. Insurers' contracts generally allow them to terminate a physician, or practice, with due cause. And fraudulent billing is definitely due cause. Without insurance coverage, expect patients to seek other options.

Further, if the insurer tells other businesses or organizations, expect additional investigations, paybacks, and loss of both patients and money.

3. Integrity Databank. The Health Care Integrity and Protection Databank keeps track of problems between physicians and third-party payers. If an insurer proves that you've billed inappropriately for overreads, it may report this to the databank. That leads to a host of other problems, including inquires from CMS, other insurers, your hospital, and licensing boards.

4. State licensing board. Some insurers may not bother to investigate your practice but report their suspicions directly to the state licensing board. That's not good news.

State licensing boards notoriously come down hard on those they suspect of lacking integrity.

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