Q&A: What Radiologists Should Know About the CMS Billing Data Release

April 17, 2014

CMS billing data was released in an effort to inform consumers. Here, a medical billing professional discusses how the release affects providers.

Earlier this month, the Centers for Medicare & Medicaid Services for the first time published billing data for more than 880,000 healthcare providers nationwide. This information, which includes the physician’s name and work address, is now searchable by other providers, patients and payers. The agency’s decision to reveal this data has been controversial throughout the healthcare industry as a whole.

Diagnostic Imaging spoke with Megan Rodden, director of operations for HealthPro Medical Billing, about what the publication of this detailed, identifiable information could mean for radiology and its practitioners.

[[{"type":"media","view_mode":"media_crop","fid":"24011","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1638293310936","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2023","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"border-width: 0px; border-style: solid; margin: 1px; float: right; height: 210px; width: 200px;","title":" ","typeof":"foaf:Image"}}]]

Will Medicare’s billing data release affect radiology? If so, how?

It absolutely affects radiologists because each physician’s payments from Medicare are available with the physician’s name for the public to review. This is something that hasn’t been available for quite some time. And, the interpretation of that data, based on the average consumer’s knowledge of physician revenue, is going to be tricky. The media has picked it up and has sensationalized a few individual stories based on the raw data. It creates a negative current for radiologists and all specialists because it tells stories of multimillion-dollar yearly jobs. It would create an environment with less empathy for discussions of physician reimbursement that have yet to occur and that each presidential administration is going to have to pursue.

Will all providers potentially be impacted the same or could some sub-specialties feel more of an effect?

The doctors that rank at the top are mostly ophthalmologists and oncologists. What the data doesn’t show is those doctors have higher direct expenses, such as the medical devices and pharmaceuticals they have to pay for to use in their practice. This is perceived more negatively by the public because they correlate more reimbursement with higher expenses for the patient. The average consumer doesn’t generally realize the expenses associated with a physician practice. They don’t view them as entrepreneurs, but many physicians and physician groups fall into that category. Physicians are running a business, and they need to be profitable. They must pay their staff and be able to contribute to their communities. Some specialties will be affected more, but it will likely be practice-by-practice. A center that does its own imaging or has to supply its own interventional radiology products may have higher costs than a hospital-based practice where the hospital is in charge of providing those supports.

What do providers need to know about this move?

Primarily, they need to know their information from Medicare, including procedure values in HCPCS and CPT, any billing changes, payment amounts – it’s available for anyone who wants to find it and download it. And, it’s right next to their full name – they’re personally responsible in the eyes of the consumer. Consumers have little plain language to help interpret or understand what it all means. It’s a good idea for physicians to take a look at what the data is saying about them. They should remember that it doesn’t include expenses. It’s not broken down for work or practice expenses or quality of care or the professionalism offices provide. It’s an unfortunate situation that the raw data in this genre never captures physicians’ passion for helping people or their education or personal investment. And doctors are very invested in a patient’s well-being – that’s just never captured in the numbers.

Are there billing behaviors that will be more closely scrutinized? What should providers do to ensure the impact on their offices and practices isn’t limited?

There may be billing behaviors that will be more scrutinized because this is a microscope. What’s most concerning for me is that the Centers for Medicare & Medicaid Services has had this data for quite some time, and there are already audit processes in place to identify fraudulent activity – or there are supposed to be. Any glaring issues that come up from this release are things that should have been dealt with long before now. I think, providers should continue to comply with their compliance programs. All providers and practices should have some sort of program, and complying is an important thing. They must know the facts about their business so they can identify any information about themselves that’s incorrect. It would be best if they establish a reputation of quality in their community and referring base, especially when patients and physicians have a choice of radiologists. It may be a situation where a payer tries to persuade patients to seek care elsewhere because of cost, but the goal is for patients to have quality in mind.

Are there any concerns that people have discussed that will likely become non-issues?

It all may depend on how the data is used. The data currently lacks accurate and correct interpretations. Doctors in the community are saying outside the media that there is concern over what data has been put out there and what resources are out there to help in interpreting the data so it can be accurately used.

Where do you think the billing data release will push the healthcare community?

You should never underestimate the value of supply and demand. The impact that will have in the years to come maybe have more push or pull over where the healthcare community goes than the release of these numbers do. I don’t think it’s going to result in an informed consumer. One of the things CMS wrote to the American Medical Association was their belief that the release would assist the public’s understanding of Medicare fraud, waste and abuse. I don’t know how well the data captures that long-term goal without adding different data and additional metrics. It could open the doors to patient steerage. As patients, we all want low-cost healthcare. Everyone would prefer to pay less, but we also want quality for our families, whatever the price tag. Payers want patients to go doctors or hospitals with lower prices but reasonable quality. A problem could arise when patients want to pay more and providers don’t give them the option. I want my healthcare decisions to be between my family and my provider. Payers and what they do with the data could be impactful. This provider billing data is available to everyone. Providers can check prices of their competition and adjust their fees to meet the market of their community. Aside from all that, patients in this situation generally don’t understand that regardless of pricing, most physicians have payer contracts that cap the amount they can get paid. Very few patients pay full charge. Patients may interpret the bill charges as what hits the physician’s checkbook. Most patients don’t have all that info to use when making their decisions. It’s not clear what this is going to do to the community, but it will be an interesting time now and into the future.