Uncompensated Services in Radiology: Cost of Doing Business

Editing reports, talking with patients, consulting with referring physicians, tumor conferences, quality improvement, reading prior films, following up on incidental findings: there’s no CPT code for that, so why do work that’s unbillable when there’s a virtual stack of images to review? The question of how radiologists can add value while not earning hard-earned dollars is a continual one. But the question may be changing in this shifting health care payment system.

You Actually Do Get Compensated
Rather than questioning why you don’t get paid for each service, maybe it’s time to reframe the issue. “I challenge the fundamental statements I hear in the radiology community, that I don’t get paid for this stuff,” said Richard Duszak, Jr., MD, vice chair for health policy and practice, department of radiology and imaging sciences at Emory University School of Medicine. “You don’t get paid. You get compensated or rewarded.”

Duszak said he dug into the database for the resource-based relative value system (RBRVS), the way CMS determines its payments. “There’s clinical vignettes for every service in the Medicare fee schedule,” he said, with three components for radiology services. They include pre-service, intra-service and post-service.

“Everybody focuses on intra-service work,” he said. “I did an interpretation. I dictated a report.” But pre-service, before the patient is on the scanner, you have to review the old images, talk with the technologist and coordinate a protocol, he said. Post-service work includes discussing the findings with patients and/or the referring physicians.

“You have been getting paid for this service. Are you telling me that you haven’t been doing it?” Duszak said. “For people to say these are services that are uncompensated right now is a misstatement. It’s considered in the overall compensation or value.”

This is politically unpopular with some physicians who don’t want to get out of the work station, he said, but it’s a critical perspective to consider. “The people in health policy making payment decisions are thinking this way,” he said, so ignoring this is dangerous to a radiologist’s future.

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The most common type of compensation, said Duszak, is a direct payment, fee-for-service. “I personally think that’s a short-sighted view of how we get paid,” he said. “People who are only looking at the very transactional way of getting paid are putting themselves on a path toward commoditization. If you only compete on the minimum service to get the price, you get to race to the bottom, and that’s not a race I want to win.”

He said that many radiologists are practicing, at least in part, in a larger organization. “Keep in mind that part of how you get paid is predicated upon you maintaining your contract with that hospital or health system,” he said. “If you do the bare minimum in a market that’s rapidly consolidating, and in which radiology groups are getting displaced, and all you provide is the minimum, that may be enough to get you by until your hospital CEO fires you and hires another radiology group.”

With payments moving toward value as part of the payment determination, doctors must provide more than just interpretive services to stay ahead, Duszak said.

Showing Value
To show his radiology group’s value to Elkhart Hospital in Indiana, Samir Patel, MD, a breast imager with Radiology Inc. and its value management program director, started tracking his group’s hours spent on value-added services. He implemented the system in 2013, ultimately identifying 36 radiology and practice management tasks that couldn’t be billed with CPT codes. He tallied up the hours and presented the findings to Elkhart’s board of directors, showing that the radiologists spent 9,932 hours in value-added services, an average of 135 hours per doctor that year. He ultimately created a value-added matrix, publishing his findings in the JACR in March 2015.

“Most groups are probably doing all this, but not categorizing, quantifying, and presenting it in a logical fashion,” Patel said. At Elkhart Hospital, “we’ve become the role model for documentation and presenting [how we’re adding value]. The beauty is that radiology is seen in a completely different light now by other specialties and the administration.”

Value Leads to Other Revenue Streams
The upside of the value-added system is that there are additional revenue streams not always related to CPT codes. But the practice must be able to perform and capture the right measures.

He divided the 36 activities into four silos. Under the quality silo, Patel said that getting their outpatient facilities accredited prevents income erosion. They get incentives from Meaningful Use involvement, participation in PQRS, and qualified data registries. They earn over-reading fees for studies interpreted by other specialties. “It’s been shown that a radiologist can add value by decreasing false positives,” he said.

Under the service section, practices can negotiate turn-around time incentives. They can implement critical test result management software, as preventing risk is a way to gain profit. His group received a malpractice premium discount for doing so. A practice can earn a health shortage subsidy from the federal government by providing service to underserved areas.

In the resource management silo, practices can negotiate self-editing incentives. For hospital-based work, transcription costs are reimbursed under the technical component.

“If self-editing, we do part of the technical component of work even though we’re not being reimbursed for that,” Patel said.

By reducing back-end transcription and shifting some of the work to radiology groups, the group can use this as a negotiating point and receive bonus payments for shared savings. Other revenue enhancement options are partnering with vendors, consulting on product development, and co-management agreements.

Patel’s practice looks at six things in the profit enhancement area: revenue increase, subsidies, incentives, shared savings, cost avoidance, and cost reduction. They try to identify activities in those areas to improve profit. “It adds up pretty quickly,” he said. But how quickly?

Last year, about 5% of their total group income was from non-CPT income. “Going forward that number will probably go higher because of MACRA legislation,” he said. Four years ago, they earned less than 1% from non-CPT income. The federal, state, and local incentive programs are becoming important for revenue, he said.

See the sidebar for how to implement this value-added matrix in your own practice.

The Responsibilities of Working in a Health System
While some groups negotiated agreements where they’re paid to participate in departmental quality improvement activities, others look at that as a routine part of doing business. If you’re part of an integrated health practice, the standards are that doctors need to do these things without additional compensation, said Duszak.

What Duszak does see as a future struggle for radiology groups is implementing the 2014 Protecting Access to Medicare Act (PAMA). This mandate requires referring physicians to use appropriate use criteria and clinical decision support to order advanced imaging for Medicare patients. Radiologists may question if they have to help triage examinations coming into the department, said Duszak.

If the automated process shows that a patient has a low appropriateness exam score, radiology groups will decide what to do. “Those are the cases where we’ll want to make ourselves very available to have consultations, to make sure the referring physicians are thinking correctly” he said. This includes determining whether the appropriateness criteria are faulty, or the physician needs education.

That could mean putting a radiologist on phone duty each day, “pulling someone from making money reading films, and putting them on the phone and potentially shutting down the flow of films coming back to the rest of us,” he said. That’s difficult for radiologists to understand. However, “if that radiology practice is going to participate in an accountable care organization or bundled payments, they’re going to have to participate or they won’t be perceived as a team player as the institution does the right thing at the right time for the patient.”

The Cost of Doing Business
Duszak said that when he was in private practice, he consulted with attorneys in a variety of areas. He’d regularly give the attorneys 20-30 minute phone consultations at no charge, with the understanding that some of these cases would turn into paid work. Similarly, if radiologists aren’t willing to take phone calls from referring physicians, the group’s contract might be terminated. “There’s work you need to do to keep your business open,” he said. “This is customer service, this is running a business.”

It comes down to understanding the customer’s idea of value, and customers include patients and referring physicians.

“We’re moving into high deductible plans, where the patients are paying the first $2,500-5,000. They’re going to be shopping for groups,” he said. If they don’t like your bill or your service, they’ll go elsewhere.

“It’s not so much what the radiologist thinks is important, it’s what the patient thinks. That’s how business works outside of health care. Whether we like it or not, we’re increasingly being asked to act like a business,” Duszak said.

How to Add Income Streams While Developing Your Value-Added Program

The new CMS payment models are a zero-sum game, meaning that the pot of money won’t change, but some doctors will get rewarded for showing value while others are financially penalized for not doing enough. To keep revenue up and show hospitals and health systems your group’s significance, radiologists need to proactively share what they’re doing with stakeholders.

Never pass up on opportunity to tell a story about the value the radiology group is providing,” said Samir Patel, MD, Radiology Inc.’s value management program director.

Patel developed a value-added matrix for his practice, showing Elkhart Hospital in Indiana that his radiology group spent 9,932 hours in 2013 on activities like outcomes measurement, executive meetings, committee work, radiation dose management, structured reporting, and practice project improvement. His matrix included 36 activities, some tied to future non-RVU income streams, some tied to the new MACRA legislation and MIPS quality program, and some administrative.

There will be winners and losers in the new payment models,” he said. “These are the sorts of things groups will need to do to have value enhancement going forward.” Here are Patel’s tips for starting your own tracking and reporting system.

• Scale it: Start small and only track a couple of inputs at first. That might be each physician’s committee and conference attendance, and meetings with administration. “We started small at one hospital with several activities, and subsequently increased the number of activities. Then we took it to other hospital locations,” he said.
• Keep a log: The log can be paper or electronic, but should include the radiologist, date, and specific activity. His group initially used paper logs. Then they graduated to a smart phone app in which radiologists can enter their activities by location, categorizing it into one of the 36 choices. “Everyone has a unique HIPAA-compliant account, submitted to a centralized data base,” he said. “That’s been a lot easier for the physicians to input data.” The entry numbers increased, and are usually done right after the activity ends.
• Consolidation: The logs should be centrally collated by an administrative leader or staff member. Talley them up every month, or every six or 12 months. The administrator can combine the non-RVU hours with billable hours, to give a total radiologist productivity measure.
• Accept different levels of participation: Some physicians will do more than others, and that’s fine, said Patel. “The key is to have everyone engaged to some degree,” he said. “The strength of the group and organization should be defined by involvement to some degree of most, if not everyone, not just a few people.” The program is an effective way to highlight those who are doing a lot of extra services outside of directly billable work. With 36 areas of value in the matrix, there should be something for every radiologist.
• Leadership: Have an administrative champion and preferably a physician champion to promote the program.
• Share results: Give the results to the practice members in addition to clients, like the hospital administration.

“It’s important for radiologists to sacrifice and take some expeditions outside the reading room to be involved in other activities,” Patel said. The good news is that most groups are probably doing these activities already, just not categorizing, quantifying, and presenting them in a logical fashion.