Bolstering the Team: Outsourcing Final Interpretations and Billing

For Kalvinder Sumra, MD, medical director at Pembina County Memorial Hospital, Cavalier, ND, the challenge has never been keeping his radiologists happy. The challenge has been finding radiologists in the first place. “We don’t have any radiologists on staff,” Sumra says. “That’s the challenging part of our setup. We had a radiologist who came to Cavalier three days a week, but when he retired, we were left without anyone.” The rural hospital produces 20 or 30 studies a day, many of them trauma cases, but recruiting a radiologist who’s willing to move to this remote corner of North Dakota is next to impossible. “Most radiologists don’t want to come to a rural area like this,” Sumra says. Fortunately for Sumra and his team, when the part-time radiologist retired in 2004, Emergency Radiology Services LLC (ERS), operated by St Paul Radiology, St Paul, Minn, was able to take over—from a distance. Pembina turned over both its night interpretations (four or five a day, according to Sumra) and its day readings to ERS, purchasing final interpretations with billing from the teleradiology provider. When NightHawk Radiology Services LLC, Coeur d’Alene, Idaho, acquired the St Paul Radiology business office in 2007, this program became known as Finals Plus, the service Pembina currently uses. For Sumra, the decision to turn over both final interpretations and billing to an outsourced provider was easy.

“It’s absolutely more feasible for us to work with a service like this than to hire a radiologist. It would be more expensive to hire a full-time radiologist, even if we could find one who was willing to work here.” —Kalvinder Sumra, MD, medical director Pembina County Memorial Hospital, Cavalier, ND

In Pembina’s case, the Finals Plus service is actually more efficient for almost all readings than the part-time radiologist had been. “It used to be that our night reads weren’t handled at all, because we didn’t have a radiologist every day,” Sumra says. “When those needed to be read, they basically waited for the radiologist to come to Cavalier. Otherwise, if there was any doubt about a read, the patient was sent to a different facility over 90 miles away.” The package of services offered by NightHawk is appealing even to facilities with an in-house staff of radiologists. Just ask Frank Barby, administrative director of imaging services, Wheaton Franciscan Healthcare, Waterloo, Iowa. Barby contracted with the company for emergency radiology services in January 2006, at which time the hospital’s imaging needs were being handled by locum-tenens radiologists. In September of that year, Wheaton Franciscan signed a contract with a group of six radiologists, but the facility chose to maintain its relationship with ERS. “After we brought the radiologists on board, we used the service primarily at night, and some weekends,” Barby says. “Our guys are pretty good about reading locally, but NightHawk covers for them when the only radiologist on staff wants a dinner break, or when we’re short on radiologists because some are on vacation.” Though Wheaton Franciscan originally used the service extensively during the day, now Barby describes Finals Plus as a “seventh guy in the practice. They’ve become part of the team,” he says. “Our radiologists and our specialists here will talk with their neuroradiologists occasionally, or their musculoskeletal guys. You can call them any time you want, and if there’s a critical finding, they’ll call the emergency-department doctor before the report is even finished. Turnaround time is less than an hour.” According to Barby, Wheaton Franciscan’s radiologists now use Finals Plus around 100 times a month, or about three times a night. “It just made sense to get final reads on our nighttime cases,” Barby says. “I don’t want to save those for an overread in the morning. It’s a huge waste of time, and the take-home pay margin isn’t that great on it.” Interpretation Triage Barby and team established a set of criteria to determine which interpretations go to Finals Plus and which remain in-house. “We only send out emergency cases that the emergency-department doctors can’t or won’t read,” he says. “We can send an emergency ultrasound to Finals Plus, but in the case of something like a plain elbow radiograph or a chest film, the emergency-department doctor can read that and leave the overread for the radiologists to handle in the morning. Our group reads the routine stuff, but if the emergency-department doctor is hot to get results, we’ll send it out.” The decision to outsource billing was intuitive. “It’s a very complicated process to set up radiology billing by the hospital,” Barby notes. “We would have had to set up a whole new division in accounting, and what we would have had to do in that department to be able to handle the professional billing would have cost more than what we would have gotten in return, especially when you look at return after contractual. It’s much easier just to let NightHawk do it.” To all parties involved, outsourcing billing is seamless. “The patient gets a regular bill, just as he or she would from any other radiologist, and we get a report,” Barby says. For Sumra, it’s the one additional step necessary to take radiology out of the hospital’s hands entirely. “We used to have to submit the billing to them, but now they can just connect to our database and take the information directly,” he says. “They provide the work, they take the information, and they bill the patient. We’re not involved at all, so we don’t have anything at risk as far as the billing is concerned. Billing the patient directly works out great for us.” Sumra cites the economic efficiency of the service as a major plus. “If you don’t have any billing to do for the reading, you can’t get more efficient than that,” he says. “For us, it’s beyond the question of savings; it’s a question of survival, but it is a reasonable cost, compared with what it would cost us to do all this on our own.” “Even to hire a professional biller would have been more complicated,” Barby says. “If we were still doing the overread in the morning, we would have had to seek someone out locally. Luckily, we never had to do that.” For Pembina, Finals Plus takes the place of an in-house radiologist; for Wheaton Franciscan, the service is a supplement to an existing staff. Both facilities can now reap the benefits of having, as Barby puts it, another guy on their teams. “If my radiologist wants to read all night long, he can certainly do that,” Barby says, “but if he wants an eight-hour break, we can send out the cases. The convenience of having other people on the team (and being able to consult with them) is invaluable to our radiologists.”