Radiology physician extenders: Plan their roles before hiring

A great deal of our time has been spent trying to find ways to make ourselves more efficient. One of those ways we began looking at several years ago was reducing the time we spend in nonbillable activities and in performing procedures that our hospital affiliation requires but that are relatively time-intensive for their reimbursement. To do this, we looked into hiring physician extenders.

We encountered a variety of challenges in moving to this model. A major one was that different radiologists have different ideas about the goal in using the extenders and the occasions when they should be used. It is vital to achieve a consensus within the group for the use of physician extenders: What hours should they cover, weekday daytime only or evenings? What about weekends?

In deciding the precise role of physician extenders, make sure they are maximizing the benefit for the whole group and not just a portion of it. Set expectations for everyone by deciding if the goal is to improve lifestyle, add service, expand a part of the practice, or make some of the radiologists more available to read from the work list and do nonprocedural work.

Another challenge was deciding what exact help we needed where we needed it. A nurse practitioner may be most appropriate for aiding with consultations and clinical follow-up with a mix of procedures. A radiology practice assistant may be more beneficial if the intent is largely to help with or perform procedures. You should discuss this as a group before hiring, not find out later you hired for the wrong purpose. That said, finding a good worker with a broad skill set may be best to increase flexibility. Discuss as a group what type of procedures the extender will perform and seek consensus on this. Differences in the way the extender is employed can prove confusing for both the extender and the hospital department and can result in communication problems, impaired efficiency, and disgruntled staff.

We have also encountered challenges in appropriate use and billing for the extenders. It is critical that everyone in the practice knows and understands hospital and state rules for credentialing, as well as CMS guidelines for physician extender use and billing and third-party payer requirements for billing. There is considerable difference in what procedures various types of extenders can perform and bill for. It is critical that the billing office know these rules as well, and that you are rigorous in following proper billing practices. Nurse practitioners may bill at a reduced rate for their own services in some cases but some types of radiology practice assistants may not be able to. It may still make sense to have them assist in or perform procedures, even if they may not be billed, as long as they are allowing the radiologist more time for billable activities.

Once there is broad agreement on who you need and the role that person will fulfill, explore all options for cost containment. If you are hiring an extender to improve throughput in a hospital-based department, or who will be facilitating scheduling and nursing, consider asking the hospital to share expenses. Also, you can consider training someone already known to you, such as a technologist, who can undergo training while working for you. A trade between paying for schooling and a commitment to work for you for some time may prove very cost-effective.

Once the extenders arrive, make sure they are maximized when at work. Have a variety of clinical and nonclinical tasks they can perform. Not every day is busy with procedures. Define for them what they should do when there are not procedures to perform. They can help the practice in a number of ways—for instance, by signing medical records. This also gets back to the idea of staggered work schedules. If you do hire more than one extender, you should mandate early on that they understand each other’s roles and can share each other’s work as much as possible. Recognize however, that different types of extenders may be trained for certain tasks and may be credentialed for different jobs. Be careful not to ask them to overstep their bounds.

Lastly, regularly review their performance. This should be an ongoing internal business practice. Ask them to keep logs of their procedures and track both billings and reimbursements for them. Recognize that billable dollars may not reflect the whole of their productivity or benefit, but does at least form a basis for determining changes in their productivity. Performance reviews with the extenders are critical as well, as they serve to keep expectations on the same page and circumvent potential problems.


Dr. Woodcock is medical director for MRI at St. Joseph’s Hospital in Atlanta. He is also a member of the executive board of Atlanta Radiology Consultants and is the practice’s executive officer for finance. He may be reached at rjwatlrad@gmail.com.