While radiology isn’t typically in the crosshairs of regulatory and investigative agencies, sloppy compliance practices could doom any imaging facility, according to a presentation at the Radiology Business Management Association (RBMA) 2017 PaRADigm meeting in Chicago.
“You can still end up with the federal government knocking at your door,” said speaker W. Kenneth Davis, a partner specializing in healthcare regulation and transactions at Chicago law firm Katten Muchin Rosenman.
Davis outlined seven mistakes radiology practices can make in documentation or regulatory compliance, offering best practices to avoid these simple but detrimental errors.
1. Radiology practitioner assistants and radiology assistants
While nurse practitioners or physician’s assistants can enroll as Medicare Part B suppliers, radiology practitioner assistants (RPA) and radiology assistants (RA) are ineligible.
“If you bill for what an RA or RPA does as if the supervising radiologist did it, then you have a problem,” said Davis. “You’re effectively telling Medicare the physician did the service when the RA or RPA preformed it.”
2. Provider transaction access number
It may seem like a no-brainer, but physicians can’t bill services with another doctor’s provider transaction access number (PTAN).
“Sometimes a self-referring physician or a doctor owning an imaging center will come to a radiologist and say ‘we want you to read films at our location,’ but the non-radiologist owner will want to bill for the services using the owner’s PTAN,” said Davis. “If the radiologist provides the service, you must bill with their PTAN.”
3. Electronic signing procedure
If a test is electronically ordered, it must read ‘electronically signed by (insert ordering physician’s name here).'
“If your imaging center uses electronic ordering—which it probably does—you need to maintain a signature log if you’re getting unrecognizable signatures,” said Davis. “There’s a compliance problem with some centers who don’t have a log, so they can’t link the signatures to the referring physician.”
4. Automated reads
Computer-aided detection has been common in mammography for decades, but recent advances in artificial intelligence technology have put automated reads just over the horizon. However, if an imaging practice is going to bill for a professional component, the radiologist has to have provided a full interpretation—no ghost reading, according to Davis.
“It stands the potential to do exactly what a radiologist does,” he said. “But keep in mind, reimbursement requirements and other legal requirements aren’t there yet.”
5. PQRS/MIPS reporting
The Merit-based Incentive Payment System (MIPS) reporting period has been open since January, and imaging practices need to report at least one measure to avoid a penalty, but can possibly see a positive payment adjustment by submitting 90 days of 2017 data. According to Davis, practices should take care to ensure their reporting is fulsome and accurate—or suffer the consequences.
“Best case, you see a loss or reduction in Medicare reimbursement,” he said. “Worst case is false claim liability and de-participation from Medicare.”
Clinical decision support will likely be required for Medicare patients beginning January 2018 or 2019, depending on how the legislation unfolds. However, many private payors have required pre-authorization for years, creating compliance questions regarding remuneration or kickback liability when a radiologist provides pre-authorization on behalf of a referring physician.
The Office of Inspector General issued a favorable opinion in detailing the criteria under which they would be comfortable with a radiologist or imaging center preforming pre-authorization, but knowledge of your specific payment situation is more important, according to Davis.
“The practical advice is you need to be keenly aware of what your local payors require,” said Davis. “I’m not suggesting you can’t find a way to make this work from a federal compliance standpoint, but you need to be aware of what your payors tell you as a matter of contract.”
7. Out-of-network billing and balance billing
Out-of-network and balance billing laws can drastically vary from state to state. California, Florida and 22 other states have some form of limitations on the practice, while other states including Georgia are considering reform or already have legislation introduced.
For example, the Oregon House of Representatives has passed a bill capping balance billing of out-of-network providers at 175 percent of the Medicare price. The legislation is awaiting a vote in the Oregon State Senate, underscoring the need for imaging practices to keep up with changes in balance billing regulations.
“What you need to know is: Is this legislation pending, is it being considered, is it up for proposal…you’ve got to monitor and advocate for yourself,” said Davis. “These balance billing and out of network laws impact all providers, not just radiology.”