Feature: Imaging payments, appropriateness under OIG review
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Tom Hoffman, associate general counsel at the American College of Radiology (ACR), said in an interview that the audits and reports could affect the course of how Medicare establishes equipment utilization rates for select imaging procedures.
There are three prongs of reimbursement for selected imaging services: practice expense (general use), malpractice and physician professional cost components. The OIG is planning to examine the equipment utilization rate and other components of practice expense, targeting CT, MRI and other procedures to determine if the rates reflect “current industry practices,” according to Hoffman.
Additionally, OIG will continue its review of whether Medicare payments for emergency department x-rays and interpretations are appropriate.
In July, the Centers for Medicare & Medicaid Services (CMS) recommended a utilization rate of 90 percent for equipment priced at more than $1 million, mainly based on a March MedPAC report, as part of its proposed rule for the 2010 Medicare Physician Fee Schedule (MPFS).
Hoffman said that the MedPAC report did not provide a representative sample of the United States, which Medicare used to calculate the equipment utilization rate for national use.
“ACR welcomes informed accountability from the government agencies. Unfortunately, we have not seen that in this proposed utilization rate policy. It’s important to comply with the law. Yet we also want to help improve government implementation policy that’s sensible and based on evidence,” he said.
The Radiology Business Management Association (RBMA) recently published a study confirming that the actual equipment utilization rate nationwide is well below the 75 percent assumption called for in the House healthcare reform legislation. The Senate Finance Committee healthcare bill, which was passed on Tuesday, called for an increase of 65 percent.
It remains unclear what will develop, as a result of the OIG findings. However, Hoffman speculated that the short-term impact will be "less significant," primarily because the OIG is not expected to publish its Part B imaging payments study until 2011.
More regulations could be imposed, which might require the emergency department physicians give contemporaneous and likely final interpretations of x-rays. If approved, those regulations could affect how hospital-based radiology practices provide patient care, stated Hoffman. The OIG could issue a report that influences Medicare to raise the equipment utilization use rate, Hoffman surmised. Utilization use rate increases, he stated, could adversely affect Medicare reimbursement payments and delivery of imaging care.
The fiscal realities for many hospitals and freestanding radiology practices are that it could be difficult to replace or upgrade equipment to keep up with regulations, said Hoffman.
From a patient standpoint, the new rates could affect the quality of healthcare, particularly in rural areas. According to Hoffman, rural hospitals and freestanding practices might not be able to keep up with high equipment utilization rates. He said this could lead to more travel time for patients to receive care, as well as longer stays in hospital waiting rooms as those facilities increase use to offset higher utilization rates.
“This limits access to life-saving technology,” Hoffman stated.
Medicare will issue its final regulation on payments and appropriateness for the 2010 MPFS on Nov. 1.