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Radiology Managers Fight Private Payor Adoption of MPPR


Data is key to fighting reimbursement cuts in radiology.

A concerning trend of private payors adopting the Medicare multiple procedure payment reduction (MPPR) on the professional component of imaging was clear at this year’s Radiology Business Management Association (RBMA) Fall Educational Conference.

This cut, which Medicare has applied since 2012, has now also become the policy of many of the nation’s largest insurance companies, despite the vigorous assertions of radiologists, radiology practice owners, and practice managers that the MPPR cut on the professional component of imaging is inappropriate.

“I think I am more concerned about the MPPR than anything else right now,” Christie James, FRBMA, secretary and director-at-large for the RBMA Board of Directors, told Rep. Michael Burgess (R-Tex.) at his presentation at the RBMA Fall Educational Conference.

In October, more than 1,800 physicians signed a letter from the ACR to UnitedHealthcare asking the insurance company to not adopt the government’s MPPR policy for diagnostic imaging services. UnitedHealthcare declined to change and may still go ahead with the cut despite Congress legislatively changing the size of the Medicare MPPR cut on the professional component of imaging from 25% to the 5% in the Consolidated Appropriations Act of 2016 that was signed into law shortly before the end of 2015.

“Hopefully [Congress reducing the size of the MPPR cut] creates the opportunity to have a dialogue with United because otherwise United would say it is just following the government’s guidance on this and not doing anything different than what the government has determined is appropriate,” said Mark Jensen, CEO of Charlotte Radiology & Carolinas Imaging Services in Charlotte, NC. “It should give us some assistance in that regard, but there are definitely no guarantees…the problem with United is that while I may have leverage in Charlotte, they are not going to make a unique change for me on policy because they can’t implement different policies across the country. I have to show hopefully through negotiations the impact this [cut] has and try to recoup those losses if they agree with me through other means, such as a rate change.”

The Snowball Effect
The reason the RBMA along with the ACR and other groups representing the field of radiology have been so concerned about the MPPR on the professional component of imaging is not just because it was a substantial cut. Radiology has, after all, faced major cuts before and been able to leverage technology to do more with less and keep care quality high.

Rather, it is because CMS never released data demonstrating that the efficiencies that would justify the cut were actually there, even after Congress passed legislation in 2014 mandating that CMS share this data with Congress, noted Liz Quam, executive director of the CDI Quality Institute in Minneapolis and chair of the RBMA Federal Affairs Committee. Since private payors almost always follow CMS’s lead on payment policies, the precedent that would be set by an unsubstantiated cut being allowed to stand would be a dangerous one.[[{"type":"media","view_mode":"media_crop","fid":"44567","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6900112593627","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5000","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":"height: 211px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Kev Draws/Shutterstock.com","typeof":"foaf:Image"}}]]

“They are causing a snowball rolling downhill because of what the commercial health plans are doing to follow suit, and it is all based on false pretense from CMS as far as we can tell,” Quam said. “It is just not about the pay cut, it is the principle of cuts not being applied unless there is actual data showing there are efficiencies there.”

Private payors following CMS policymaking is a “double-edged sword,” explained Jensen, which is part of the reason why many contracts allow payors to make changes that follow government policy without sitting down to renegotiate the contract. While radiology wants private payors to quickly follow CMS on the coverage of new tests, such as CT lung cancer screening, it does not want it to be as quick to follow on cuts. The private payors, who have to answer to their customers and stock holders, have the opposite motivation, being eager to reduce reimbursement when there is a justification for lower reimbursement and reluctant to expand coverage to new tests and procedures.

Radiology business managers and owners are often the ones to meet face-to-face with the private payors during contract negotiations and are typically the first to receive notices from private payors when they plan to change a policy to mirror Medicare and Medicaid policy. They, therefore, have an important role to play in educating private payors about cuts that lack good justification data, such as the MPPR.

“Whenever I can get an audience with private payors about this subject, I do talk about the impact of the MPPR on quality,” said Linda A. Wilgus, CPA CMPE, executive director and CFO of Northwest Radiology Network in Indianapolis, IN. “Radiologists will do the right thing, no matter what. They are going to read every study at the highest level of quality and specialization they can. However, you want your radiologists to take the time and read a study carefully and consult with referring physicians. You don’t want them hurried or rushed, and if you have the continual pressure to move on to the next exam and the next exam, quality is going to suffer. I talk about, if this was your mother having these studies, wouldn’t you want the time and attention devoted to making sure you have the most accurate diagnosis possible?”

In theory, unlike with Medicare, practices can threaten to walk away from a private payor contract that underpays them for services. In reality, however, such a recourse can be highly impractical because insurance companies have become larger and one or two may have the dominant market share.

“When the commercial [payor] adopts a government reimbursement cut, in our state, Blue Cross, it has a significant impact because they pay us more than Medicare does, so the economic impact is more significant,” Jensen said.

Fighting back is done at many levels using various tools, he added, with the first question typically being whether the contract permits the commercial payor to adopt the same policies as the government. “A lot of it has to do with relationships, leverage, and the contract language itself,” Jensen said. “In some cases, they may not be able to unilaterally make a change to your fee schedule, and in other cases they can. Then you have to look at what your options are to fight back, whether it is terminating the contract or going to arbitration. All of which are dramatic, and the payors know that they can adopt certain cuts and policies and the providers may find the effort to defend it is deemed to be too expensive and difficult and they will just accept it. It is a tough world and a lot of it you fight at the state level through your department of insurance commission and try to develop fair provisions in the contract language that will protect against unilateral changes by the payors.”

Fighting Back with Data
Since countering the MPPR cut one private payor at a time is nearly impossible, much of the focus of organized radiology has been on reversing the Medicare MPPR cut in the hope that private payors will then reverse their MPPR cuts as well. The success of this effort could be a case study of how all sectors of radiology can work together to advocate against potentially ill-considered government policies, Jensen said.

“It takes a village to effect change,” Jensen said. “This is a short term win in a long battle ahead because this was one instance where through education, information, and data we were able to roll back a bad policy. It should serve as a guiding light for future challenges the industry faces that working together, using information both from the RBMA and the ACR, can have an impact.”

The key part radiology business owners and managers play in that village is that they have the business data to demonstrate that a cut is unfounded and may very well have long-term negative consequences.

“Numbers will tell you a story if you have the courage to listen to them,” Wilgus said. “The business managers are close to the people who do the work and really understand the whole ecosystem that is around a patient exam. We understand the costs and the overhead with every change of the law.”

Because CDI sees more than a million patients a year through its network, it has one of the largest databases of radiology practice data in the country. “We ran the numbers through our RIS and there absolutely is no efficiency on the professional side for the combination of the codes, and we can’t imagine what data CMS used to justify the MPPR on the professional component,” Quam said.

Making the quality argument, as well as the fairness argument that it is illegal for CMS to implement a cut without data justifying it, is powerful. However, in the end, what may resonate most with policymakers in government as well as chief medical officers at commercial payors are numbers that show the truth.

“Without the data, in today’s world, you cannot affect change without data and information,” Jensen said.

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