Radiology Digest – May 23, 2023

May 18, 2023

Radiology Digest: News from the week of May 23, 2023.
Experts Cite ‘Urgent Need’ for Changes to USPSTF Breast Cancer Screening Recommendations

By Hannah Murphy | May 17, 2023 | Included in Radiology Digest – May 23, 2023

Additional organizations in the women’s health space are joining others to voice their disappointment with the United States Preventive Services Task Force’s (USPSTF) draft recommendations pertaining to changes in breast cancer screening (DBI) and the Journal of Breast Imaging, the official journal of the Society of Breast Imaging, both released statements this week contesting multiple aspects of the draft recommendations, including the matter of how often women should undergo screening and the task force’s omission of guidelines relative to supplemental screening for women with dense breasts

The DBI statement described the recommendations as “disappointing,” noting that the USPSTF’s update suggests that women should screen every other year when their own modeling studies have cited the benefits of annual screening. This recommendation could be especially consequential for the development of interval cancers in between screenings. 

“Widening that gap to two years gives those cancers more time to develop and grow and interval cancers tend to be more aggressive with worse outcomes than those found on the screening mammogram,” the DBI statement reads. 

Although the USPSTF update pertains specifically to women at average risk of developing cancer, the draft did briefly touch on the matter of dense breast tissue—a known factor that increases a woman’s risk of developing cancer and also having their cancer missed on mammograms. The draft excludes recommendations that women with dense breast tissue be referred for supplemental imaging, such as ultrasound or MRI, despite mounting evidence supporting the need for additional exams in that population.

Regarding this decision, USPSTF cited “inadequate” evidence—evidence that Wendie Berg, MD, PhD, with the department of radiology at Magee-Women’s Hospital of UPMC in Pittsburgh, and colleagues were happy to provide USPSTF with in their opinion article published in the Journal of Breast Imaging (JBI).

The group cited numerous studies with ample evidence to support their call for USPSTF to update their recommendations, noting that such changes would expand coverage to women who need it the most.

“As insurance may not cover screening not recommended by the USPSTF, this needs to be addressed. People will be told the mammogram is limited in women with dense breasts, and that other imaging tests can help, but affected women may be unable to get additional such imaging tests due to lack of insurance coverage,” the JBI article notes, adding that this would limit supplemental imaging availability solely to those with substantial resources. 

Katie Couric, a breast cancer survivor herself, also addressed the USPSTF’s lack of additional guidance for women with dense breasts. Couric shared a clip of herself encouraging others to speak out on the topic during the open commenting period for the draft recommendations. That comment period ends on June 5, 2023. 

To read more, go to Health Imaging.


Insurance Commissioners Eye Cigna Following Report of Physicians Denying Claims Without Reading Them

By Jakob Emerson | May 17, 2023 | Included in Radiology Digest – May 23, 2023

State insurance commissioners and federal lawmakers are raising concerns with Cigna’s internal claims review process following reporting from ProPublica in March that said the payer denies large batches of claims without reviewing them first.

Many states require medical directors to review patient files and coverage policies before denying claims for medical reasons. ProPublica alleges that Cigna has bypassed these steps by having a computer algorithm complete the review and then having physicians sign off on groups of denied claims.

“It’s hard to imagine that spending only seconds to review medical records complies with the California law,” Dave Jones, California’s former insurance commissioner, told ProPublica. “At a minimum, I believe it warrants an investigation.”

“I’m afraid it might be the tip of the iceberg,” Washington’s insurance commissioner, Mike Kreidler, told the publication. “We darn well better start paying attention to it.”

“Given your article, this will likely warrant a closer look,” a spokesperson for Delaware’s insurance department told ProPublica.

“This is very concerning,” an anonymous Labor Department official told ProPublica. “I don’t see a scenario where we’re not taking a hard look at these kinds of practices.”

On May 16, Rep. Cathy McMorris Rodgers of Washington and chair of the House Committee on Energy and Commerce, said that Cigna’s Medicare Advantage members appeal 20 percent of denied claims, and about 80 percent of those denials are overturned.

“If these figures are at all illustrative of Cigna’s commercial appeal and reversal rates, it would suggest that the PXDX review process is leading to policyholders paying out of pocket for medical care that should be covered under their health insurance contract,” Ms. Rodgers said in a letter to Cigna.

To read more, go to Becker’s Payer Issues.


US Senators Introduce Legislation to Strengthen Payment for Diagnostic Imaging Agents

By Marty Stempniak | May 17, 2023 | Included in Radiology Digest – May 23, 2023

U.S. senators from both political parties have introduced legislation to increase payment for certain diagnostic imaging agents, drawing praise from provider groups Tuesday.

Sens. Marsha Blackburn, R-Tenn., and Tammy Baldwin, D-Wisc., first reintroduced the Facilitating Access to Innovative Diagnostics (or FIND) Act on May 10. House lawmakers proposed a similar companion bill in March.

Currently, Medicare only reimburses for radiopharmaceuticals through a packaged system. But this can create a barrier for those who need newer nuclear imaging agents, advocates note. S.B. 1544 would eliminate this obstacle by requiring HHS to issue separate payment for such agents, using a per-day cost threshold of $500.

The bill has drawn support from numerous professional medical groups. They include the American College of Radiology, American Society of Neuroradiology, the Mayo Clinic Department of Radiology, and the Society of Nuclear Medicine & Molecular Imaging.

PET is a crucial tool for diagnosing diseases such as prostate cancer and Alzheimer’s, supporters noted. Yet, this obstacle is preventing patients from accessing the modality.

“Unfortunately, a Medicare payment policy makes these tests largely unavailable,” Rachel Conant, VP of federal affairs for the Alzheimer’s Association, said in a May 16 announcement from both lawmakers. “We are grateful to Sens. Blackburn and Baldwin for reintroducing the bipartisan FIND Act, which will increase patient access to functional imaging and improved diagnosis accuracy.”

Each year, over 20 million Americans benefit from the use of diagnostic and therapeutic radiopharmaceuticals, which are needed for nuclear medicine procedures, advocates noted. They’re essential for treating other diseases such as Parkinson’s (the Michael J. Fox Foundation also is a supporter), breast and prostate cancer, heart disease, and neuroendocrine tumors.

“Flawed” reimbursement methodology, however, continues to discourage hospitals from using them.

“Anyone who’s battled diseases like cancer or Alzheimer’s knows what a difference a clear and early diagnosis can make,” Sen. Baldwin said in a statement. “Advanced imaging can be that difference, helping identify and diagnose a disease, inform more timely and appropriate treatment plans, and improve overall healthcare outcomes.”

Members of the U.S. House and Senate previously introduced the FIND Act in 2021, but the proposals failed to reach the president’s desk.

To read more, go to Radiology Business.


ChatGPT Passes Radiology Exam

By Will Morton | May 17, 2023 | Included in Radiology Digest – May 23, 2023

The latest version of ChatGPT has passed a radiology board-type exam, yet the language model’s “hallucinations” raise concerns over its reliability, according to a study published May 16 in Radiology.

Dr. Rajesh Bhayana of the University of Toronto and colleagues tested ChatGPT-4 — a recently released paid version of the artificial intelligence (AI) large-language model (LLM) — on a multiple-choice text-only test that matched the style, content, and difficulty of the Canadian Royal College and American Board of Radiology exams. ChatGPT-4 achieved a score of 81%, but the chatbot’s wrong answers raised concerns.

“We were initially surprised by ChatGPT’s accurate and confident answers to some challenging radiology questions, but then equally surprised by some very illogical and inaccurate assertions,” Bhayana said, in a news release from RSNA.

ChatGPT has potential as a tool in medical practice and education, but its performance in radiology remains unclear, the authors noted. ChatGPT-3.5 was released by in November 2022. ChatGPT-4 was released in March.

The researchers tested ChatGPT-3.5 first, with results of the study also published May 16 in Radiology. The exam consisted of 150 text-only questions designed to assess the chatbot’s ability to perform “lower-order thinking” involving knowledge recall and basic understanding and “higher-order thinking” involving descriptions of imaging findings and applying concepts.

ChatGPT-3.5 answered 69% of questions correctly (with 70% considered a passing score) and performed better on questions requiring lower-order thinking than on those requiring higher-order thinking, according to the findings.

To read more, go to Aunt Minnie.


Remote Radiologists Prioritize Financial Gain When Choosing Reads: 2 Possible Fixes

By Marty Stempniak | May 17, 2023 | Included in Radiology Digest – May 23, 2023

Remote radiologists working for hospitals appear to prioritize financially lucrative studies over more urgent alternatives, according to a new analysis.

This may be leading to critical patient care delays and additional unnecessary costs. The findings warrant possible remedies to improve efficiency and turnaround times, experts with West Virginia University wrote in the Journal of Operations Management [1].

“This research provides evidence that an intense focus on productivity as driven by the RVU may have unintended negative consequences on the level of service radiologists provide to hospitals—and ultimately to patients,” Bernardo Quiroga, PhD, an associate professor of supply chain management at WVU, said in a Tuesday, May 16, announcement from the school.

For the study, researchers analyzed information representing more than 2.1 million imaging exams completed in a popular radiology workflow program between 2014-2017.

The data set spanned 251 procedure types, performed across 62 hospitals, and read by 115 radiologists. The platform connects hospitals and off-site radiologists, who can select studies to process from a common pool. Reads ranged from “routine,” denoting no urgency, to “hyperacute,” necessitating immediate attention. In the middle were “expedited” studies (low clinical urgency but higher operational priority—i.e., if a patient is waiting on a scan before discharge) and “stat” (indicating conditions that are medically acute but not life-threatening). Roughly two-thirds of studies in the analysis were labeled as stat, which should take priority after radiologists address those that are hyperacute.

The first major finding: Lower priority tasks with a higher expected pay-to-workload ratio were discovered to have significantly shorter turnaround times. Reading times were relatively short compared to overall turnaround times, the authors noted. “This result implies that the reduction in turnaround time for nonurgent, financially attractive studies is due to a reduction in wait times for them to be picked up by a radiologist,” the authors noted.

Quiroga et al. also reported a second major finding: More financially attractive, low-priority tasks were strongly associated with longer turnaround times and an increased probability of delay for higher priority tasks. 

“We discovered that the expedited priority class contained the highest percentage of delayed studies, and those delays could be quite large,” Quiroga said in the announcement. “The workflow platform provider is contractually bound to achieve a certain level of turnaround time, so delay is an important performance measure.”

The research team emphasized that radiologists were not purposely pushing aside medically urgent exams with high clinical priority. Rather, they often neglected those with medium level “administrative” and “operational” priorities.

To read more, go to Radiology Business.


Independent Dispute Resolution Case Load 14X More Than Expected

By Jaqueline LaPointe | May 15, 2023 | Included in Radiology Digest – May 23, 2023

Nearly a year after the federal government launched the independent dispute resolution (IDR) process under the No Surprises Act, over 330,000 balance billing disputes have been filed, nearly 14 times more than the Departments of Health and Human Services (HHS), Labor, and the Treasury expected.

CMS recently published the status update on the federal dispute resolution process containing the latest numbers on initiated disputes, dispute eligibility, and results of payment determinations. In addition to confirming an ongoing backlog of IDR cases, the update also revealed a high success for initiating parties, which have largely been providers.

From when the IDR portal opened on April 15, 2022, through March 31, 2023, certified IDR entities rendered payment determinations in 42,158 disputes. Parties that filed the dispute — known as initiating parties — were the prevailing party in nearly three-quarters of those cases.

A separate report on the IDR caseload for the fourth quarter of 2022 showed that practice management companies, medical practices, or revenue cycle management companies representing hundreds of individual practices, providers, or facilities filed the most cases. The caseload was also up by 53 percent compared to the previous quarter, the report also said.

The federal IDR process is available to resolve disputes over surprise bills, which typically involve out-of-network payments. The No Surprises Act prohibits surprise bills in most scenarios involving an out-of-network provider treating patients at in-network facilities.

The IDR process continues to face a significant backlog of disputes because disputes filed earlier in 2022 more often required additional outreach and analysis in order for certified IDR entities to determine eligibility, according to the status update.

The status update found that non-initiating parties challenged the eligibility of 122,781 disputes in the first 50 weeks of the IDR process. Of the disputes closed during that period, about 39,890 were ultimately deemed ineligible for the federal IDR process.

But even if the non-initiating party does not challenge the eligibility of the dispute, the certified IDR entity must review and confirm that it is eligible before it proceeds further in the federal IDR process, the status update explained.

“These reviews involve complex eligibility determinations that required certified IDR entities to expend considerable time and resources,” the update stated.

To read more, go to Revcycle Intelligence.


Natural Language Processing Helps Increase Follow-up Imaging Adherence, Resulting in Significant Revenue

By Hannah Murphy | May 15, 2023 | Included in Radiology Digest – May 23, 2023

When used alongside nurse coordinators, natural language processing (NLP) systems present a cost-effective means of increasing radiologist-recommended follow-up adherence among patients, leading to significantly increased revenue in radiology departments. 

A new paper published in Current Problems in Diagnostic Radiology details how a team at the University of California utilized a hybrid system consisting of a quality coordinator and NLP software to bring in more than $60,000 in additional revenue from follow-up imaging alone. The team used special NLP software to identify radiology reports with follow-up imaging recommendations and refer them to a quality nurse who would then single out any incomplete cases and communicate the issue with referring providers and patients. 

Corresponding author of the paper Bradley Roth from the Department of Radiological Sciences at the university, and colleagues suggested that hybrid systems similar to theirs can improve patient care while simultaneously turning a profit. 

“The use of a hybrid human-AI system can prevent potential drops in communication and can assist in the coordination of follow-up care, while easing the burden of alert fatigue on referring providers,” the authors noted, adding that this cost-effective system also poses potential for reducing the risk of malpractice litigation. 

To better understand how the system would affect costs, revenue and follow-up adherence, the team looked at data derived from reports generated at their institution between January 2020 and April 2021.  

The NLP software (mPower Follow-Up Recommendation Algorithm from Nuance Communications) flagged 3,011 patients as not having received timely follow-up imaging, 427 of which required a nurse coordinator to place the orders. The team estimated the follow-up imaging of these patients would have resulted in an additional $62,937 in revenue based on 2020-2021 Medicare reimbursement rates. This figure was calculated as a higher amount than that of the associated personnel costs, and it likely significantly underestimates the true revenue derived from follow-up imaging, the team noted. 

“Our revenue assessment was made only on the patients that required new imaging orders to be placed with our system’s help,” the group explained. “We excluded all patients who had preexisting imaging orders but needed significant follow-up help from our quality and safety nurse to schedule and complete their imaging exams. This conservative methodology was least prone to measurement bias.” 

Even if the hybrid system did not produce additional revenue, the team suggested that its patient care benefits make its use a worthwhile investment. 

“… given the potential patient safety and medicolegal liability of potential missed follow-ups, the authors believe that, even with a net loss, this system would pose great benefits to most healthcare systems,” the group wrote. 

The study abstract is available here
To read more, go to Health Imaging.


Appeals Court Pauses Texas Ruling Against ACA Preventive Care Coverage

By Jakob Emerson | May 15, 2023 | Included in Radiology Digest – May 23, 2023

The U.S. 5th Circuit Court of Appeals has temporarily blocked a Texas court’s ruling earlier this year that struck down an ACA provision requiring payers and employers to provide coverage for preventive services.

The U.S. 5th Circuit Court of Appeals has temporarily blocked a Texas court’s ruling earlier this year that struck down an ACA provision requiring payers and employers to provide coverage for preventive services.

U.S. District Judge Reed O’Connor said in his March 30 ruling that preventive care recommendations made by the U.S. Preventive Services Task Force do not need to be complied with and blocked the federal government from enforcing its recommendations. 

About 100 million Americans use free preventive services annually, which insurers have to cover without cost-sharing. The ACA requires payers to cover more than 100 preventive health services recommended by the task force.

The ruling applies only to task force recommendations made by the panel on or after March 23, 2010 (when the ACA became law), such as statins, lung and skin cancer screenings, and pre-exposure prophylaxis, or PrEP, an HIV prevention drug. Sexually transmitted infection screenings and cancer screenings such as mammograms and cervical screenings would still be included for preventive coverage.

The Biden administration appealed the Texas ruling in early April. The 5th Circuit granted an administrative stay May 15 while the court reviews the case.

It is likely that most insurers will continue to cover preventive services, though they may raise cost-sharing for members for certain services in the future, according to the Kaiser Family Foundation. An increase in costs will not happen immediately because of current contracts, but that could change in the next calendar year. For PrEP specifically, there could be substantial cost-sharing.

Generic PrEP costs around $360 a year while branded prescriptions can reach upward of $20,000 annually.

To read more, go to Becker’s Payer Issues.

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