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Economics
Getting paid for what we do: more complex than you think
The process of reimbursement – getting paid for services provided as a
radiologist or radiology oncologist – is complex and confusing. Unlike
just about any business in the world, healthcare runs by a different set
of rules. Rather than performing a service and sending a bill to your
patient, your bill goes to one of a number of third parties. These
payors have already decided how much they are going to pay you (with
little regard to how much you are charging) and can choose to deny
payment after the fact.
The ACR plays a crucial role at every step, helping to represent all of
us to Medicare, local insurance companies, and other specialty
organizations. It is a complex and often contentious process.
Thankfully, the ACR has earned a reputation as a principled and
knowledgeable player in these negotiations. Most importantly, it is our
only representative, unique among all radiology specialty organizations
for the role it plays in economics.
Although our primary focus is always to protect the interests of our
patients and deliver excellent care, we should all understand the
economic forces that guide our specialty. Spend some time learning the
basics of Economics on these pages – though we are seldom taught these
things as residents, they are crucial to our everyday practice.
The Basics
Every radiology and radiology oncology service is represented by a CPT®
(Current Procedure Terminology) code. Once a code has been created, it
is assigned a value (RVU, or Relative Value Unit) that determines the
amount that this service will be paid by Medicare. But the process
doesn't end there: every local administrator of Medicare (a Medicare
Carrier) will determine appropriate indications for each service.
Certain combinations of services will be excluded through edits (CCI)
that prevent someone from billing for both services at the same time.
Local insurance companies use the CPT® codes as a starting point, and
then create unique sets of appropriate indications, reimbursement rates,
and exclusions, often different from Medicare. And even Medicare has
created different systems for reimbursement, with different policies
that vary according to the setting (hospital vs. outpatient).
So there are many steps in the process, each of which requires
negotiation and discussion. Because there are many different players in
the process, the ACR must work at both the national and local levels to
ensure that there are no loopholes that result in unfair reimbursement.
Author:
Sanjay K Shetty, M.D.
Past RFS Chair & James M. Moorefield Fellow
Continue reading to learn about the details of the process.
Learn more:
- Reimbursement, demystified
- Creating a CPT® Code
- Assigning a Value to the Code
- Reimbursement
Other links:
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