According to a recent legal analysis published by the Journal of the American College of Radiology, it’s becoming more and more common in the U.S. for patients to seek help from radiologists without a physician referral.  

Laurie T. Cohen, a partner at Nixon Peabody LLP, and Brooke Lane, an associate with the firm, detailed some key information radiologists should know before accepting any “self-referred” patients. These are some of the most important facts from their analysis:

1. Different states have different rules

It should surprise no one that states have their own laws regarding the standard of care in radiology for self-referred patients; it would be too easy to memorize otherwise.

In New York, the authors explained, x-ray screening is permitted without a primary care provider’s referral in certain situations: screening programs must gain approval from the Department of Health, all screening must be supervised by a licensed radiologic clinician, and so on. Self-referred mammograms include even more specific regulations.

“There are additional requirements for self-referred mammographic screenings, including a requirement to provide palpation and teaching of breast self-examination,” Cohen and Lane wrote. “Furthermore, the mammographic screening program operator must perform an annual analysis of false-positive and false-negative findings and submit a report to the Department of Health.”

The authors also listed requirements specific to Arizona and Virginia. In the Grand Canyon State, facilities where self-referred mammograms are taking place are required to submit a “physician-approved guide” for accepting self-referred patients, and medical physicist evaluations must also be sent to the Arizona Radiation Regulatory Agency.

Meanwhile, in the Old Dominion State, the state’s health commissioner is required to grant prior approval to “healing arts screening programs.”

2. Medicare’s one exception

As a rule, Medicare requires patients to have treating physicians order their diagnostic tests, but screening mammography is an exception.

Also, the authors provided an important detail about who CMS considers to be a patient’s “treating physician.”

“The CMS guidance defines a treating physician as ‘a physician who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results of a diagnostic test in the management of the beneficiary’s specific medical problem.’” Cohen and Lane wrote. “When performing a therapeutic interventional procedure, a radiologist is considered a treating physician. A radiologist performing a diagnostic interventional procedure or diagnostic procedure, however, is not considered a treating physician. This distinction is significant because, to the extent that a radiologist is performing a diagnostic interventional procedure or diagnostic procedure and therefore is not considered a patient’s treating physician, the radiologist cannot issue the order for such diagnostic procedures.”

3. It is crucial to develop certain protocols

The authors suggested that radiology groups accepting self-referred patients should develop a thorough protocol for referring patients to a primary care physician or a specialist in cases where there are suspicious findings.

“In developing such policy or protocol for referrals for follow-up care, such arrangements must also comply with federal and state antikickback and physician self-referral laws,” Cohen and Lane wrote. “Namely, there shall be no remuneration or payment in exchange for such follow-up referrals. Physicians have an ethical obligation to obtain informed consent before rendering any patient care service.”

4. Payments may still be denied

The authors highlighted that, even if payers can legally accept self-referred patients, they may still deny payment if there is no physician’s order. You have been warned.