Radiologists and Billing: Accountability Without Control
Looking for an enlightened approach to billing isn’t easy amid a sea of third-party payor excuses, absurd addendum requests and CT headers seemingly etched in stone.
One of the last elements of a typical doctor’s education, if it is included at all, is the matter of getting paid for his or her services.
“Fine!” some might say. “Let them learn about being good physicians instead.” There is an ever-growing body of medical knowledge, effectively infinite, and nobody is going to absorb it all. If we took even an hour of medical learning away in order to cover financial stuff, some tidbit that might have helped save or improve a patient’s life could get left out.
We could just as easily apply that reasoning to lawyers, engineers, and any other profession of interest, but I am not about to delve into that now.
When docs do finally learn a little something about the business aspect of health care, a lot of them swiftly wish they hadn’t, and are glad of any excuse not to learn more. It is a complicated mess that makes little sense. The more you understand it as a physician, the more you see just how little control you have over your own profession. It is an economically nonviable house of cards that has long since been taken over by a horde of middlemen and regulators.
A lot of docs don’t even try to navigate those waters and satisfy themselves as employees or contractors for entities that will take on the trouble of dealing with insurers and CMS. My career is typical. I have worked for hospitals and assorted rad groups where I get a negotiated salary, hourly rate, or per-RVU amount. They can make sure that whatever they collect for my services exceeds what they pay me (or decide if it is worth losing money on me for the bigger picture).
Much as we would like to be, radiologists opting for such arrangements aren’t completely shielded from the hassles of billing. Almost every job I have had included an orientation in which we were reminded of things that have to go into our reports, lest a third-party payor have an excuse not to reimburse for already rendered services. They endlessly concoct new excuses so we constantly have new verbiage crammed into our dictating mouths.
A rad might shrug that off. He or she is getting the paycheck. Let the hospital worry about whether or not it will collect a few bucks for a chest X-ray that showed up with no clinical history. Depending on where the rad works, however, he or she may be more on the compliance hook than the rad previously thought.
The mechanism has changed over the years but the upshot is the same. The billing people reach out with a request that some report or other “needs” to have an addendum saying certain magical words that will appease the insurance gods. You didn’t mention the aorta in an abdominal ultrasound, you didn’t say MIP or 3D in a CTA, or you didn’t list contrast dosage.
Whatever the case, it never adds to patient care. Rather, it detracts, usually from other patients. The rad has to take time away from reading current studies to do this housekeeping for the bean counters, especially if the billing people decide the matter is urgent. Sometimes, billing saves up a bunch of these demands and sends them all at once. A rad can lose half an hour with one of these batches.
It has crossed my mind that a lot of health-care systems likely have some sort of mechanism in place for whenever a rad makes an addendum to a report: All clinical personnel covering the patient in question probably get an alert that they need to review the report again, lest something important was said. Of course, whatever billing compliance thing we just said is of no value to them, and they get interrupted/annoyed for nothing.
My prime vexation among these time wasters (I can’t even call it a pet peeve. No pet should be hated this intensely) is when I am working in a system in which I cannot alter the order for a study. The header is etched in stone for CT ABD/PELV WO CONTRAST, for instance, but I pull up the study and there is, in fact, contrast.
The study needs to be read, and the tech or whoever else might be able to change the order is busy or otherwise unavailable. I read the thing out, making sure to put in my “Technique” section that the header is in error, and the study in fact utilized amount X of contrast agent Y. I would have corrected the header, but, again, it is etched in stone, beyond my ability to fix.
Even this is a deviation from my work as a diagnostic radiologist. In the time it took me to notice and address the discrepancy, I could have evaluated much of the regional anatomy. Commenting on liver, spleen, etc. is what I am supposed to be doing and what the referrer wants. No health care is rendered by my billing appeasement side quest, although it does add bulk to my report, more words for the referrer to sift through as he or she tries to extract information of actual worth.
My preemptive action probably works sometimes but I am only aware of when it doesn’t. Fast forward a week or a month, and I hear from billing. They want an addendum clarifying whether or not contrast was used. It doesn’t matter that I already explained this in the Technique section. The header says otherwise so there are two statements contradicting one another. I suppose billing (or the payor) thinks that the addendum will make a “best 2 out of 3” tiebreaker.
When I was younger and more eager to please, I would go ahead and do it. Add sufficient years and salt content, and I knocked that off. No, I am not going to make an addendum that simply repeats what my report already said. In addition to wasting my time, it will make me look particularly stupid to whatever clinicians see me knuckling under.
I have worked in a couple of places (including, hallelujah, my current gig) where they have had a more enlightened view. Essentially, the billers are willing/able to take my verbal statement when they think the header and technique are at odds. I don’t know how that translates to their communication with the third-party payors, and I don’t care that much. It leaves me and the referrers alone.
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