Radiology Digest – September 5, 2023

August 31, 2023

Radiology Digest: News from the week of September 5, 2023.

House Conservatives Flirt with Shutdown: ‘So be It’

By Michael Schnell and Emily Brooks | August 30, 2023 | Included in Radiology Digest – September 5, 2023

Congress is racing the clock to fund the government ahead of a Sept. 30 deadline as the threat of a shutdown looms — but to some House conservatives, a shutdown isn’t much of a threat at all.

A handful of hardline Republicans are brushing off — or even embracing — the possibility of a shutdown, arguing that bringing the government to a screeching halt is more acceptable than allowing the country to continue on its current spending trajectory.

“If a shutdown occurs, then so be it if they’re not gonna stick to what [Speaker Kevin McCarthy (R-Calif.)] agreed to, which is starting on a path of financial security, which we don’t have,” Rep. Ralph Norman (R-S.C.) told The Hill in an interview.

Rep. Bob Good (R-Va.) — who in July said “we should not fear a government shutdown” — went even further when talking to The Hill last week.

“Eighty-five percent or so of the government continues to operate, and most Americans won’t even miss it,” Good said. “And if that’s the leverage that we need to utilize to force the Democrats to accept spending cuts and an end to the harmful policies that are, again, crushing the American people — I mean, then we need to do that.”

While the Republicans flirting with a shutdown are a tiny minority within the GOP conference, they add another layer of complication for McCarthy as he works to keep the lights on in Washington without angering his right flank, who are pushing for steeper spending cuts and policy additions as part of the appropriations process.

McCarthy is asking House Republicans to help him pass a “short-term” continuing resolution, or CR, to fund the government beyond Sept. 30 as both chambers slog through the government funding process. The House has cleared just one of 12 regular appropriations bills, while the Senate has not gotten any past the finish line. The House will be in session for just 11 legislative days until the end of fiscal 2023.

To read more, go to The Hill.


American College of Radiology Voices Concerns Around CMS’ Approach to Bolstering Payment for Emerging Technologies

By Marty Stempniak | August 30, 2023 | Included in Radiology Digest – September 5, 2023

The American College of Radiology is voicing concerns about the Centers for Medicare & Medicaid Services’ proposed approach to expediting payment for emerging technologies.

Federal officials first released the proposal in June, hoping to grant seniors “more timely and predictable” access to innovative new treatment and diagnosis methods. This new “Transitional Coverage for Emerging Technologies,” or TCET, pathway for breakthrough devices would support patient care and innovation by providing a “clear, transparent and consistent coverage process while maintaining robust safeguards for the Medicare population,” CMS said at the time.

ACR this week detailed its apprehension about the scope and utility of the program as proposed while agreeing that a fresh approach is needed.

“We are concerned that TCET will not address certain fundamental coverage, coding and payment issues facing innovative technologies and will not adequately support the volume of new products coming to market,” CEO William T. Thorwarth Jr., MD, wrote in a Aug. 28 letter to the CMS administrator. “Appropriate candidates for the TCET pathway include devices with a Medicare benefit category but do not address the need to reexamine the definition of existing benefit categories to include many innovative devices. Overreliance on this criterion will leave emerging technologies without appropriate Medicare reimbursement under the TCET pathway.”

CMS has said that its goal is to finalize a Transitional Coverage for Emerging Technologies determination within six months after FDA market authorization, the college noted. And it intends to have that coverage continue as long as it is needed to facilitate the timely generation of evidence to inform patient and provider decision-making around new devices.

Thorwarth listed several potential remedies to address the college’s concerns. Those include evaluating CMS’ current national coverage determination pathway to ensure it is granting efficient market access for advanced imaging solutions, radiopharmaceuticals, contrast agents and focused ultrasound therapies. ACR also encouraged the agency to issue earlier guidance on how to coordinate coding and payment applications to secure Medicare reimbursement for such technologies. In coordination with the Food and Drug Administration, ACR is asking officials to maintain an up-to-date list of all breakthrough devices CMS is considering for the TCET program. And the college is advocating that CMS add more staff while assessing other resource constraints to help streamline this new process.

“ACR appreciates CMS’ recognition that medical specialty societies ‘have valuable expertise and first-hand experience’ in the field that will help CMS develop Medicare coverage policies,” Thorwarth wrote. “We will continue to monitor the opening of a TCET [national coverage determination] analysis and offer guidance where possible. We urge CMS to communicate with specialty societies regarding relevant opportunities to provide feedback and encourage CMS to be flexible regarding the time it takes specialty societies to collect evidence and determine consensus perspectives as they pertain to coverage decisions.”

The Medical Imaging and Technology Alliance, which represents device manufacturers, issued its own comments on the proposal on Aug. 28. In a news update issued Wednesday, ACR said it looks forward to seeing the final procedural notice and CMS’ implementation plans.

To read more, go to Radiology Business.


CMS to States: Fix Your Broken Medicaid Eligibility Systems

By Rylee Wilson | August 30, 2023 | Included in Radiology Digest – September 5, 2023

CMS is urging states to correct an issue that could result in eligible people being removed from Medicaid. 

On Aug. 30, the agency sent a letter to Medicaid directors in all 50 states, informing them automatic renewal systems in several states are calculating eligibility at the family income level, rather than the individual level.
According to a news release from CMS, this can result in improper disenrollments, especially for children, because family members may have different eligibility requirements. 

“Children often have higher eligibility thresholds than their parents, making them more likely to be eligible for Medicaid or CHIP coverage even if their parents no longer qualify. This conflicts with existing federal Medicaid requirements and may have a disproportionate impact on children,” the agency wrote in the release. 

CMS did not name which states it believed were incorrectly conducting these renewals. In the letter, the agency urged state directors to determine if their automatic renewal system has issues and take steps to correct it and reinstate enrollment for those affected. 

If states fail to identify issues with their automatic renewal system, they may be required to submit a corrective action plan to CMS. If the state does not implement corrective action, they could face financial penalties, according to the letter to state Medicaid directors. 

According to KFF, as of Aug. 29, over 5.5 million people have been disenrolled during the unwinding of continuous coverage requirements. Of those disenrolled, 4 in 10 are children. 

Earlier in August, the agency warned 27 states they had “concerning” rates of procedural terminations. Of those disenrolled from Medicaid, 3 in 4 have been disenrolled because of procedural reasons, rather than being determined ineligible by CMS, according to KFF. 

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


Another No Surprises Act Win: Qualifying Payment Amount Process was Tilted in Insurers’ Favor, Judge Rules

By Marty Stempniak | August 29, 2023 | Included in Radiology Digest – September 5, 2023

Radiologists and other physician specialists have scored another key court victory in the ongoing battle over the No Surprises Act, advocates said Monday.

A Texas judge ruled Aug. 24 that methodology insurers use to calculate the “qualifying payment amount”—the basis for negotiations over out-of-network reimbursement—is tilted in payers’ favor. The court is now disallowing several provisions related to how the QPA is determined, including incorporating “ghost rates” for services that radiologists and other docs do not provide.

“The ruling is a step toward an independent dispute resolution process that is accessible, fair and efficient,” Jacqueline A. Bello, MD, chair of the American College of Radiology Board of Chancellors, said in a statement issued Aug. 28. “The insurer-calculated QPA process is a ‘black box’ that drives unsustainably low reimbursement, undermines practices’ ability to provide care and may reduce patient access to in-network care. The government must issue rules to make the IDR process work as the law intended.”

U.S. District Judge Jeremy D. Kernodle’s order additionally would allow self-insured group health plans to use rates from all payers handled by a third-party administrator in calculating the QPA. This is the court’s fourth such ruling on the “flawed” implementation of the No Surprises Act, ACR noted, which came in response to lawsuits filed by the Texas Medical Association. ACR, the American College of Emergency Physicians and the American Society of Anesthesiologists filed an amicus brief earlier this year, stating their support for the suit.

The three specialty societies issued a joint statement Monday, noting that the government will now have two months to appeal the ruling.

“If it stands, this decision will end a status quo that allowed insurers to game the system at the expense of community-based physician practices,” ACR et al. said. “This important ruling will bring the law back in line with what Congress intended for the No Surprises Act—protecting patients from surprise bills and creating an unbiased mechanism to resolve payment disputes between insurers and physicians.”

The departments of Health and Human Services, Labor and Treasury have not yet indicated how they’ll proceed following the decision. The NSA’s arbitration process remains on hold following another key court ruling on Aug. 3, which vacated the 600% fee increased for independent dispute resolutions under the landmark law.

ACR and the emergency medicine and anesthesiology societies emphasized that the latest decision does not impact patient protections spelled out in the NSA, which they support.

“While we await federal agency rules regarding the court’s decisions, it is now clear that the rules governing the application of the NSA and the establishment of the QPA should not be weighted in favor of the insurance industry,” Bob Still, executive director of the Radiology Business Management Association, told Radiology Business Monday. “This decision will clearly benefit physicians and more importantly their patients.”

To read more, go to Radiology Business.


Study Finds Extent of Diagnostic Imaging Studies Interpreted by Non-physicians Practitioners to be Increasing

By Tom Greeson | August 28, 2023 | Included in Radiology Digest – September 5, 2023

n new article just published by the journal Current Problems in Diagnostic Radiology, a research team from the Harvey L. Neiman Health Policy Institute follows up on their prior work measuring the extent of utilization of non-physician practitioners (NPPs) – specifically nurse practitioners (NPs) and physician assistants (PAs) – employed by U.S. radiology practices. This latest study was not limited to use of NPPs by radiology practices. The study assessed broadly the growth of diagnostic imaging billed by NPPs across the United States, finding an increase in the rates of diagnostic imaging studies interpreted by NPPs. Of note, the authors document the surprising, and concerning, increase in NPP imaging interpretation of advanced imaging studies such as CT and MRI. 

This was a retrospective study using patient claims for diagnostic imaging studies performed between 2016 and 2020 from Optum’s Clinformatics Data Mart The data was modeled to determine the likelihood of patients receiving NPP-interpreted vs physician-interpreted imaging. The rates and trends in proportions of NPP-billed claims for interpretation services were then assessed based on urban versus rural settings, as well as differing state scope-of-practice (SOP) regulations and legislation.

Over 110 million diagnostic imaging claims were reviewed with most (97%) attributed to physician interpretation services. But looking at NPP-billed imaging interpretation claims, the highest share of diagnostic imaging interpreted by NPPs occurred in 2020 (3.3%), up from 2.6% in 2016, a 26.9% increase over that time span.

Of the imaging studies interpreted by NPPs, 79.4% were either radiography/fluoroscopy (53.3%) or ultrasound (26.1%).

In their evaluation of diagnostic imaging of state-level NPP practice authority, researchers observed increases in both metropolitan and micropolitan areas when comparing states with more restrictive NPP scope of practice laws to states with more moderate laws. But those states with more moderate scope of practice laws saw the larger increases in rates of imaging interpretations by NPPS.

The most surprising finding to me was the extent of computed tomography and magnetic resonance advanced imaging (CT and MRI) interpretation services found to be performed by NPPs. A 2019 American Journal of Roentgenology reported that non-advanced imaging (i.e., radiography/fluoroscopy) accounted for 94% of NPP imaging interpretation.A study of NPPs working in radiology-only practices published earlier this year by the Journal of the American College of Radiology — also the work of a research team from the Harvey L. Neiman Health Policy Institute — found that bone densitometry and swallowing studies accounted for 87% of NPP-billed imaging. The new study found that NPP interpretation activity was somewhat focused on radiography/fluoroscopy (53%) and ultrasound (24%).  But surprisingly, the combined percentage CT and MRI made up of 21% of the overall NPP-interpreted imaging. 

As noted above, the authors, correctly in my view, express concern over the extent of NPP imaging interpretation of advanced imaging studies, given NPPs’ deficiencies in imaging training.

One can expect ongoing research in the extent to which NPPs are performing radiology services. Some of this is alarming, but some has to be expected given the manpower shortages among physician specialties, including radiology.

I hope that researchers will also turn their attention to tracking the utilization of NPPs in the supervision of diagnostic imaging tests that require administration of contrast. Both Medicare rules and ACR’s practice parameters accept NPP supervision of Level 2 tests to the extent permitted by a state’s rules and the NPP’s state scope of practice regulations.

To read more, go to ReedSmith.

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