Tighter Rules on Utilization Rates, Self-Referrals

PHILADELPHIA – Health care reform, in the guise of the Patient Protection and Affordable Care Act signed into law by President Obama last spring, will have unique impacts on nuclear cardiology practices as they deal with new regulations on utilization of imaging equipment and self-referrals.

Despite rumblings of overturning the law, Dr. Kim Williams said at the annual meeting of the American Society of Nuclear Cardiology that health care reform is here to stay. “It would be very difficult, though not impossible – but very difficult to flip a house of Congress and to repeal this.” Regulations will be phased in over the next 4 years, he said.

The equipment utilization rate that Medicare uses to establish reimbursements is due in 2011 for an adjustment for three types of imaging – MRI, CT, and PET – but excludes single photon emission computed tomography (SPECT). Dr. Williams of Wayne State University in Detroit, described the equipment utilization rate as “a mechanism to actually decrease reimbursement.” Medicare actually rolled back the rate for MRI, CT, and PET from 90% to 50% in 2010, but will bump it back up to 75% in 2011, he said.

Meanwhile, the Affordable Care Act tightens requirements on self-referrals. Dr. Williams raised a hypothetical situation familiar to all nuclear cardiologists. “Running an EKG – is that self-referral? Yes,” he said, “but it hasn’t come onto anyone’s radar screen because it isn’t a lot of money.” He cited other “elements of the house of medicine” with accusing cardiology and other specialties of inappropriate self-referral.

Like the equipment utilization rate, the disclosure provisions on self-referral cover MRI, CT, and PET but not SPECT, at least not yet, Dr. Williams said. “Most of us look at that [from the viewpoint that] a patient expects a self-respecting practice to own its equipment, so it isn’t that onerous,” he said. “But the devil is in the details.”

Among those details he outlined: “One will have to inform patients in writing at the time of the referral that they can obtain services from someone other than the referring physician or someone in the referring physician’s practice.”

That takes the form of a list of at least 10 other providers within a 25-mile radius, including phone numbers and distance. Dr. Williams outlined the ASNC’s comments on the regulation. “First of all, it should not include any imaging beyond CT, MRI, or PET,” he said. “It’s certainly not going to go any further than 25 miles, and the list requirement should be only for five other providers.” The higher number might compel cardiologists to include providers of questionable quality, he said. The final regulation should be ready by November to go into effect on Jan. 1.

The Affordable Care Act also empowers the Medicare Payment Advisory Commission (MedPAC) to make nonbinding recommendations to Congress on payment revisions. One problematic area MedPAC is looking at is developing payment tools that take into account providers’ utilization rates, Dr. Williams said. “If your utilization is high, you get less reimbursement,” he said. “The problem with that is that nobody mentioned risk adjustment.”

Another goal of MedPAC is to bundle payments for more groups of procedures. “For what we do, there aren’t an awful lot of efficiencies that can be bundled,” Dr. Williams said. MedPAC also may target prior authorizations for providers who have a high volume of studies: “sort of a radiation benefit manager pre-authorization service,” is how Dr. Williams described it.

ASNC is hoping MedPAC steers clear of these two areas: limiting the types of services the in-office ancillary exception covers and excluding payment for any service that’s not provided in an initial office visit. “That’s not going to fly,” Dr. Williams said of the latter.

Dr. Williams called on his colleagues to take an active role in shaping these regulations as they’re written by engaging their representatives. “You should be able to get involved with this. You should be weighing in on every piece of legislation and every Medicare regulation that affects nuclear cardiology,” he said.

Dr. Williams had no relevant disclosures.

PHILADELPHIA – Health care reform, in the guise of the Patient Protection and Affordable Care Act signed into law by President Obama last spring, will have unique impacts on nuclear cardiology practices as they deal with new regulations on utilization of imaging equipment and self-referrals.

Despite rumblings of overturning the law, Dr. Kim Williams said at the annual meeting of the American Society of Nuclear Cardiology that health care reform is here to stay. “It would be very difficult, though not impossible – but very difficult to flip a house of Congress and to repeal this.” Regulations will be phased in over the next 4 years, he said.

The equipment utilization rate that Medicare uses to establish reimbursements is due in 2011 for an adjustment for three types of imaging – MRI, CT, and PET – but excludes single photon emission computed tomography (SPECT). Dr. Williams of Wayne State University in Detroit, described the equipment utilization rate as “a mechanism to actually decrease reimbursement.” Medicare actually rolled back the rate for MRI, CT, and PET from 90% to 50% in 2010, but will bump it back up to 75% in 2011, he said.

Meanwhile, the Affordable Care Act tightens requirements on self-referrals. Dr. Williams raised a hypothetical situation familiar to all nuclear cardiologists. “Running an EKG – is that self-referral? Yes,” he said, “but it hasn’t come onto anyone’s radar screen because it isn’t a lot of money.” He cited other “elements of the house of medicine” with accusing cardiology and other specialties of inappropriate self-referral.

Like the equipment utilization rate, the disclosure provisions on self-referral cover MRI, CT, and PET but not SPECT, at least not yet, Dr. Williams said. “Most of us look at that [from the viewpoint that] a patient expects a self-respecting practice to own its equipment, so it isn’t that onerous,” he said. “But the devil is in the details.”

Among those details he outlined: “One will have to inform patients in writing at the time of the referral that they can obtain services from someone other than the referring physician or someone in the referring physician’s practice.”

That takes the form of a list of at least 10 other providers within a 25-mile radius, including phone numbers and distance. Dr. Williams outlined the ASNC’s comments on the regulation. “First of all, it should not include any imaging beyond CT, MRI, or PET,” he said. “It’s certainly not going to go any further than 25 miles, and the list requirement should be only for five other providers.” The higher number might compel cardiologists to include providers of questionable quality, he said. The final regulation should be ready by November to go into effect on Jan. 1.

The Affordable Care Act also empowers the Medicare Payment Advisory Commission (MedPAC) to make nonbinding recommendations to Congress on payment revisions. One problematic area MedPAC is looking at is developing payment tools that take into account providers’ utilization rates, Dr. Williams said. “If your utilization is high, you get less reimbursement,” he said. “The problem with that is that nobody mentioned risk adjustment.”

Another goal of MedPAC is to bundle payments for more groups of procedures. “For what we do, there aren’t an awful lot of efficiencies that can be bundled,” Dr. Williams said. MedPAC also may target prior authorizations for providers who have a high volume of studies: “sort of a radiation benefit manager pre-authorization service,” is how Dr. Williams described it.

ASNC is hoping MedPAC steers clear of these two areas: limiting the types of services the in-office ancillary exception covers and excluding payment for any service that’s not provided in an initial office visit. “That’s not going to fly,” Dr. Williams said of the latter.

Dr. Williams called on his colleagues to take an active role in shaping these regulations as they’re written by engaging their representatives. “You should be able to get involved with this. You should be weighing in on every piece of legislation and every Medicare regulation that affects nuclear cardiology,” he said.

Dr. Williams had no relevant disclosures.

PHILADELPHIA – Health care reform, in the guise of the Patient Protection and Affordable Care Act signed into law by President Obama last spring, will have unique impacts on nuclear cardiology practices as they deal with new regulations on utilization of imaging equipment and self-referrals.

Despite rumblings of overturning the law, Dr. Kim Williams said at the annual meeting of the American Society of Nuclear Cardiology that health care reform is here to stay. “It would be very difficult, though not impossible – but very difficult to flip a house of Congress and to repeal this.” Regulations will be phased in over the next 4 years, he said.

The equipment utilization rate that Medicare uses to establish reimbursements is due in 2011 for an adjustment for three types of imaging – MRI, CT, and PET – but excludes single photon emission computed tomography (SPECT). Dr. Williams of Wayne State University in Detroit, described the equipment utilization rate as “a mechanism to actually decrease reimbursement.” Medicare actually rolled back the rate for MRI, CT, and PET from 90% to 50% in 2010, but will bump it back up to 75% in 2011, he said.

Meanwhile, the Affordable Care Act tightens requirements on self-referrals. Dr. Williams raised a hypothetical situation familiar to all nuclear cardiologists. “Running an EKG – is that self-referral? Yes,” he said, “but it hasn’t come onto anyone’s radar screen because it isn’t a lot of money.” He cited other “elements of the house of medicine” with accusing cardiology and other specialties of inappropriate self-referral.

Like the equipment utilization rate, the disclosure provisions on self-referral cover MRI, CT, and PET but not SPECT, at least not yet, Dr. Williams said. “Most of us look at that [from the viewpoint that] a patient expects a self-respecting practice to own its equipment, so it isn’t that onerous,” he said. “But the devil is in the details.”

Among those details he outlined: “One will have to inform patients in writing at the time of the referral that they can obtain services from someone other than the referring physician or someone in the referring physician’s practice.”

That takes the form of a list of at least 10 other providers within a 25-mile radius, including phone numbers and distance. Dr. Williams outlined the ASNC’s comments on the regulation. “First of all, it should not include any imaging beyond CT, MRI, or PET,” he said. “It’s certainly not going to go any further than 25 miles, and the list requirement should be only for five other providers.” The higher number might compel cardiologists to include providers of questionable quality, he said. The final regulation should be ready by November to go into effect on Jan. 1.

The Affordable Care Act also empowers the Medicare Payment Advisory Commission (MedPAC) to make nonbinding recommendations to Congress on payment revisions. One problematic area MedPAC is looking at is developing payment tools that take into account providers’ utilization rates, Dr. Williams said. “If your utilization is high, you get less reimbursement,” he said. “The problem with that is that nobody mentioned risk adjustment.”

Another goal of MedPAC is to bundle payments for more groups of procedures. “For what we do, there aren’t an awful lot of efficiencies that can be bundled,” Dr. Williams said. MedPAC also may target prior authorizations for providers who have a high volume of studies: “sort of a radiation benefit manager pre-authorization service,” is how Dr. Williams described it.

ASNC is hoping MedPAC steers clear of these two areas: limiting the types of services the in-office ancillary exception covers and excluding payment for any service that’s not provided in an initial office visit. “That’s not going to fly,” Dr. Williams said of the latter.

Dr. Williams called on his colleagues to take an active role in shaping these regulations as they’re written by engaging their representatives. “You should be able to get involved with this. You should be weighing in on every piece of legislation and every Medicare regulation that affects nuclear cardiology,” he said.

Dr. Williams had no relevant disclosures.