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What’s Driving Utilization & Your Reimbursement?


There are several things you should know about what’s driving utilization of your services and your payments for providing them.

After a long roller-coaster ride, diagnostic imaging utilization nationwide is finally stabilizing, industry experts say. But, questions still remain about why the leveling out has happened – is it the reigning in of inappropriate imaging? Or are services actually being cut?  At the same time utilization is plateauing, your reimbursement rates are being somewhat whittled away by the continued move toward bundled payments and various reporting requirements. Overall, industry experts say, 2017 brings changes worth watching. What’s Driving It All? Despite its rapid growth in the late 1990s to 2006, diagnostic imaging services have been stringently cut back in recent years. Now, however, said Richard Duszak, Jr., MD, vice chair of health policy and practice at Emory University School of Medicine’s Department of Radiology and Imaging Services and senior research fellow at the Harvey L. Neiman Health Policy Institute, utilization isn’t seeing the same level of curtailing.  Campaigns, such as Image Wisely, have led physicians to double-check whether imaging is necessary, but the decrease has largely leveled off. There are still several factors, though, that drive the use of diagnostic imaging.  1. Patient conversations: Patients are spending more time educating themselves on imaging options, and they’re coming to appointments ready to discuss possibilities with you. In these situations, remember to advise your referring physicians to adhere as close as possible to Image Wisely, Image Gently, and ALARA principles. 2. Emergency Department (ED): This driver is not yet fully understood, Duszak said, but according to recent Neiman Policy Institute research, imaging utilization in EDs is on the rise. According to Neiman Policy data, the total Medicare cost of imaging in the ED between 2003 to 2014 grew from $243 million to $566 million.  A lack of familiarity between ED providers and patients could be behind increased use. Doctors aren’t as familiar with a patient’s history, and the patient isn’t as confident with a doctor they don’t know, so a diagnostic image could be ordered to assuage worries. “It’s all about how quickly you can get a patient through the ED and maintain satisfaction and workflow,” he said. “Rather than bringing someone in for observation, or potentially keeping them overnight for a costly hospital stay, you can get an quick answer with a CT or other imaging test.” 3. Clinical Decision Support: Considered a requirement under the Medicare Access & CHIP Reauthorization Act (MACRA), the use of clinical decision support tools by your referring physicians is also impacting imaging utilization, said Ezequiel Silva, III, MD, the Chairman of the American College of Radiology’s Commission on Economics. In some cases, its guidance is eliminating unnecessary services, and in others it’s ensuring you’re asked to perform the correct service. Either way, your reimbursement levels are still tied to whether your referring physicians consulted the tool prior to ordering a study. “It’s still early to know how this legislation will impact payments, but providers need to be aware of the metrics and how they will be judged and processed,” he said. “Bonuses and penalties will be based on performance.” However, there are factors that are keeping utilization at bay, he said. 1. Insurance, but no access: More patients have insurance under the Affordable Care Act, but new research shows insurance still doesn’t equal access. In some cases, patients don’t have access to the primary care physicians needed to refer them for imaging studies.   2. Closures & Cutbacks: Unfortunately, a portion of the utilization stabilization stems from the shuttering of some imaging centers nationwide. Other facilities have seen a scale-down because they cannot afford to buy upgraded tools, such as new MRI magnets, that ensure they can deliver needed patient services. 3. Affordable Care Act Transparency Initiative: This initiative is designed to help patients determine which doctors are more expensive compared to their peers, Duszak said. Referring physicians who order more diagnostic tests could be deemed pricier than their colleagues, potentially making them less attractive to patients. This published data could influence whether physicians opt to order a potentially questionable test. What’s Affecting Reimbursement? As with previous years, the Centers for Medicare & Medicaid Services (CMS) is alternating using reimbursement as both a carrot and a stick. Whatever the case, your payments aren’t increasing, and you’ll have to continue jumping through hoops to secure your dollars. 1. MACRA: This legislation lays out reporting requirements that will go into full effect in 2019. However, the preparatory phase began on Jan. 1, 2017. There are several ways to participate, but if you are involved for the full year, you can maximize the positive payment adjustment you could receive.  There is concern, though, Silva said, that you and your colleagues, as well as your referring physicians, will become exhausted with the reporting responsibilities. “The increased regulatory burden placed on practices and the increased cost of doing business can create the risk that fewer providers will do it,” he said. “There’s a real concern that radiologists will get overwhelmed and say it’s not worth the effort to participate.” 2. Omnibus Bill: Overall, outpatient reimbursement is set to increase 1.65 percent, but under this legislation, the industry is required to continue its phase out of film and computed radiography (CR) X-ray in favor of digital radiography. If you don’t, you’ll experience a 20-percent payment reduction for 2017 with analog X-ray systems, and an equivalent reduction for CR equipment in 2018. 3. Mammography: CMS announced three new bundled payment codes for mammography with computer-aided detection: one for unilateral diagnostic mammography, one for bilateral diagnostic mammography, and one for screening mammography. New payments will go into effect in 2018, allotting for an increasing of the diagnostic mammography payments and no change in the screening mammography payment. Additionally, no change to the technical component payment is anticipated.  4. Multiple Procedure Payment Reduction (MPPR): According to the Bipartisan Budget Act of 2015, CMS is set to reduce the professional component of MPPR from 25 percent to 5 percent this year.  What’s Next? Regardless of the factors driving utilization or reigning it in, as well as the legislation and regulations impacting your reimbursement, you can largely expect the diagnostic imaging playing field to look similar for a while, Duszak said.  “We’ve had stability in imaging over the last few years,” he said. “And, with the aging population continuing to need imaging services, we’ll likely see things staying the same for the foreseeable future.” 

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