A Matter Of Perspective
By Curtis Kauffman-Pickelle

An old saying has it that where you stand on a particular issue depends on where you sit. In other words, one’s point of view is heavily dependent on one’s frame of reference and milieu.

A case in point: not too many years ago, I bought stock in a high flying data storage company that seemed to be unstoppable. The stock price kept climbing and turned my $4 per share investment (cost basis, after splits) into an incredible $100-plus powerhouse. I had visions of retiring to paradise only to ride the stock all the way back down to $10 or so. So do I consider myself lucky that I doubled my investment? Of course not. My perspective is based on what once was.

I learned that an intelligent view toward investing includes an understanding of the fundamentals of the businesses one invests in. Market share, debt load, innovation, etc are all part of that due diligence. As a result I am a more informed investor.

So what does this have to do with outpatient imaging?

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In a typical year, more than 10,000 bills and resolutions are introduced in Congress and fewer than 5% of these actually become law. So while radiology advocates celebrated another victory in August — a Senate bill to reverse cuts to Medicare payments for radiology — these long odds were definitely in the back of their minds.

“I am a little more relieved, but I have got the blinders on until September,” said Josh Cooper, senior director of government relations for the American College of Radiology. “I’ve been in enough of these to know that it is not over until it is over.”

The Senate bill — S. 3795, the Access to Medicare Imaging Act — calls for a 2-year moratorium on medical imaging reimbursement cuts included in the Deficit Reduction Act of 2005 (DRA). The bill also requires a comprehensive Government Accountability Office (GAO) study to analyze the impact of the DRA payment methodology on patient access. Introduced on August 3, it is the companion bill to the House bill — H.R.5704, the Medical Imaging Act of 2006 — which was introduced on June 28. Should both bills make it out of committee, be voted on, and pass, they would then be combined into a House-Senate joint resolution, voted on again by both Houses, and sent to the president to be signed into law.

If this sounds like a lot, it is. No single-issue bill, like the DRA moratorium, is likely to survive such a process. To pass, a single-issue bill must typically be attached to a larger provision with more political clout behind it.

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Survival of the Most Efficient
By Nicole Pliner

As demand for imaging continues to grow, so too do the challenges of running an efficient and viable radiology practice. Competition is fierce, utilization scrutiny is intensifying, radiologist shortages continue, turf battles are becoming more and more prevalent, and reimbursement challenges loom darker and darker. How will radiology practices survive this new era of imaging? The answer, as evidenced by other industries faced with similar challenges, is looking inward at the operation and creating the most efficient and productive workflow possible. However, most practices are so busy with day-to-day operations that they do not take the time to step back and seriously analyze their workflow. Even when new technology is introduced or equipment upgrades are implemented, workflow is not re-examined.

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Fraud and Which IDTFs?

Headlines charging imaging centers with fraud appeared in various places following a report issued in June by the Office of Inspector General (OIG). At the behest of the Department of Health and Human Services, the OIG audited Medicare claims paid to independent diagnostic testing facilities (IDTFs), and found $164,839 in overpayments by Medicare in 2001, extrapolating an additional $71.5 million in improper payments. The report cited two categories of improprieties in its findings: services were not always reasonable, necessary or ordered by a physician; and facilities did not always report operational changes, as required by Medicare. Of its most egregious findings, the report stated: “Of the 230 sampled beneficiaries, who received 1,804 IDTF services, 80 beneficiaries received 1,231 services that did not comply with applicable federal laws, regulations, and guidelines. We also found a marked pattern of repetitive use of services. Fifty-five of the sampled beneficiaries accounted for 1,095 of the 1,231 questioned services. These beneficiaries received their services from IDTFs in California and Florida.”

Does that sound like the sort of fraud even the most aggressive imaging center operator could perpetrate? Or might it more accurately describe a lab testing facility? When questioned on this front, according to a report on imagingeconomics.com, staff at the OIG was not immediately able to calculate what percentage of improper payments were made for imaging tests or how many of the tests were performed at freestanding imaging centers. Sleep and allergy tests are mentioned in the report, as well as ultrasounds and EKGs.

However, the report did come down specifically on at least one imaging center for lapses in physician oversight, one of the greatest challenges for imaging centers today. Unless a center is equipped with a centralized reading station, only the busiest of imaging centers could justify the fulltime presence of a radiologist. The report stated: “Of the 219 IDTFs that provided services to the sampled beneficiaries, 191 did not comply with initial enrollment application and subsequent update requirements. IDTFs did not report operational changes such as the identity and number of technicians and supervising and interpreting physicians, type, model number of equipment and tests performed.” In fact, the report stated, of the 133 IDTFs that did not report changes in the identity of their supervising physicians, 6 ceased to have a supervising physician at all and 70 IDTFs were found to employ supervising physicians that did not perform their duties.

Because the OIG did not supply the number of actual freestanding imaging centers involved, it is not possible to accurately report how many transgressions can be attributed to imaging center operators. However, it is conceivable that some imaging centers may have been culpable. Pay attention to the paperwork and nail down your physician oversight situation. The OIG is gunning for you.

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Review of Claims Billed by IDTFs for Services Provided to Medicare Beneficiaries During Calendar Year 2001

MEMRAD: Nothing Left But the Memories

News of the demise of one of radiology’s largest and most innovative radiology practices, MEMRAD Medical Group of Long Beach, Calif, provided a sobering moment for radiology practices bent on positioning themselves as regional providers. At its height, MEMRAD boasted 80 members, staffed nine hospitals and 10 imaging centers, and operated a successful teleradiology service and busy practice management company, Radiology Practice Management. The dissolution of the group has left client hospitals scrambling for coverage, members adrift, and a field day for lawyers.

A long-time observer of the California radiology scene. Gregory Kusiak, MBA, president-elect of the Radiology Business Management Association, practice manager for Pasadena-based practice The Hill Medical Corp, and president of a billing and practice management company in Arcadia, offers these cautionary words for out-sized practices.

“If you look at accounting and law firms, they have a well-established pattern of bringing in junior woodchucks at a rather low income and working them half to death. The excess of their earning is available for the distribution to their partners. You have a very hard time doing that with physicians. That’s the large challenge of any group that tries to put itself together over a large geographic distribution.”

— Gregory Kusiak, MBA

Nonetheless, practice trends support the movement toward larger practices: subspecialty radiology and in-house nighthawk coverage demand size. Regulatory and payor trends also support the construction of large practices over regional geographies. Clearly, the challenges are tremendous. Proceed with caution.

click here to read more about >> Imaging Trends: A Forecast for 2005-2007

click here to read more about >> State of the Practice

The Key to the Kingdom: Informatics

Never before has it been more clear: informatics is a key component in both streamlining imaging center operations and extending the reach of your resources. A novel application of informatics was reported in the recent edition of Imaging Economics. Advanced Imaging Services Inc (AIS), a San Antonio-based imaging company, once plied its trade by sending technologists from a central location to its customer base of rural hospitals, then nursing homes to x-ray the ailing residents, who frequently had to be hunted down by staff while the tech stood by idle. When the x-ray was finally obtained, the film had to be delivered back to headquarters.

AIS has transformed its mobile imaging operations by equipping Scions with a DC-to-AC inverter, a mobile CR system from Kodak Orex, an accompanying laptop, an ImageGrid IG700 server from Candelis, and a GPS navigator. The call comes in for the x-ray, the nearest tech is located and alerted, and the nursing home staff is advised to have the patient ready and waiting. Once the image is obtained, the technologist transmits the digital images using wireless portals like those offered for free or via paid monthly pass at Starbucks, FedEx Kinko’s, and even Dairy Queen.

The AIS system, which was designed by Dicom Solutions Inc, Aliso Viejo, Calif, utilizes mobile imaging modalities coupled with today’s free Internet services—including wireless hotspots that are popping up around the country and free navigational tools like Google Earth.

“We offer heart echocardiograms, ultrasound, bone-density testing, and x-ray,” AIS president Phil Rathbun told Imaging Economics, explaining how AIS eventually edged out competing mobile x-ray services. “As our business changed, we were able to move rapidly from rural hospitals—which eventually will get their own ultrasound machine and technicians and everything—into the nursing facilities.”

Once the images are acquired, the technologists drive to a local hot spot to upload images to the internet. Once the images are received by headquarters, they are transmitted to a radiology practice in Florida for the diagnosis. “We just move to the local Starbucks, where we have an [Internet] account, and we send right there from the café while we’re having a latte,” Rathbun said. He laughed and added, “Everybody in Starbucks is probably thinking, ‘Man, the Internet is getting kind of slow all of a sudden,’ as we’re blowing these 20-megabyte x-rays through the system.”

This is one novel practice model and a brilliant application of imaging informatics and free Internet services.

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Riverside Radiology: IT Grows the Practice