Health Reform’s Impact on Imaging

Plenty remains unknowable about the incipient impact of the Patient Protection and Affordable Care Act of 2010 (PPACA), but the act does stand to affect imaging providers, specifically through its compliance, fraud, and payment provisions, many of which have already taken effect or will take effect in the near future.The statute gives an unprecedented level of authority to the secretary of HHS, relying on that office to define and narrow the scope of broad concepts. For instance, the bill states that the DHHS may impose a series of requirements for Medicare-reimbursed providers, ranging from criminal background checks to unannounced site visits. Although it could take years for HHS to determine how it will interpret some of the bill’s mandates, imaging providers should begin preparing now for what is already shaping up to be an environment of increased scrutiny and oversight.Compliance and EnrollmentAlthough enrollment and credentialing for Medicare are no small feats under current regulations, PPACA mandates that HHS issue new, more stringent regulations to screen all providers and suppliers receiving Medicare, Medicaid, and TRICARE reimbursement. The bill suggests that the HHS consider imposing criminal background checks, fingerprinting, unannounced site visits, and application fees for providers not yet in the programs, for newly enrolled providers, and for providers revalidated as of September 23, 2010. Providers may also have to disclose any affiliations they have with other providers or suppliers that have uncollected debt, that have been suspended or excluded from any of the above programs, or that have had their billing privileges revoked. One thing is clear: PPACA requires providers’ participation in federally reimbursed health plans to be subject to the precondition of having a compliance program of some nature. Imaging providers can prepare for this eventuality by establishing a compliance plan as soon as possible, ensuring that they will be able to meet whatever requirements HHS issues within a short time. Providers should also begin sanctions screening of their affiliated providers and suppliers to ensure that their enrollment is not denied based on another organization’s debt or billing issues. Practice managers should keep an ear to the ground, staying up to speed on any statements issued by CMS and by their local Medicare audit contractor. Upping the stakes, penalties for failing to meet new enrollment requirements will also be steeper under PPACA: Anti-kickback civil monetary penalties will be increased to $50,000 per false statement in any application, bid, or contract to participate in a federal health-care program, and the secretary of HHS will have the ability to exclude individuals from participation.Fraud and AbuseIn keeping with these new provisions, PPACA mandates an expansion of the Recovery Audit Contractor (RAC) program to Medicaid; by 2011, all state Medicaid agencies must contract with a RAC, with the goal of identifying and recovering all under- and overpayments associated with services provided under Medicaid plans. Providers not up to date on their state’s Medicaid policies should prepare for increased scrutiny and ensure that they are billing correctly, understanding that Medicaid billing requirements do occasionally differ from those of Medicare. PPACA also adds a new provision to Stark self-referral regulations, applying them to MRI, CT, PET, and any other diagnostic health services deemed appropriate by the secretary of HHS. According to the new regulation, which became effective January 1, physicians performing these ancillary diagnostic services in their offices must provide written notice to beneficiaries that they may obtain the services elsewhere, complete with a list of alternative sites in the area where the patient resides. Payment and OverpaymentAlready in effect are new requirements for reporting overpayments from CMS. Although overpayments have always been subject to the False Claims Act, which required providers to report them and return the balance to CMS, PPACA updated this requirement to specify that surplus payment must be returned within 60 days and must be accompanied by a written explanation of the discrepancy. Some (but not all) Medicare carriers currently require submission of an overpayment refund form, and Medicaid carriers rarely do. An example of an overpayment form can be seen here:
A sample overpayment refund/notification document There is some good news in the bill, primarily in new payment provisions. A 1.0 work floor extension of the Geographic Practice Cost Index to December 31, 2010, should boost reimbursement for rural radiology providers. PPACA’s modification of the utilization-rate assumption for imaging equipment also stands to benefit radiology, which was previously scheduled to face a 90% utilization rate by 2014, but will now contend with a more manageable 75% utilization rate. In addition, PPACA restores payment for dual-energy x-ray absorptiometry services furnished this year and next to 70% of what was paid in 2006; this mandate is retroactive to January 1, 2010, although a retroactive payment process is yet to be established. The Physician Quality Reporting Initiative (PQRI) gives providers the opportunity to earn bonuses based on implementation of quality-enhancing measures. PQRI payment benefits begin in 2011, while penalties for not participating in PQRI will kick in four years later, in 2015, underscoring the importance of implementing the program as rapidly as possible. In 2011, providers will be able to earn a 1% bonus for successful participation and an additional 0.5% bonus for participating in a qualified American Board of Medical Specialties Maintenance of Certification program. That bonus will decrease to 0.55% for successful participation in 2012, 2013, and 2014. In 2015, a penalty of 1.5% of allowed charges will be assessed for nonparticipation. On the opposite side of the reimbursement coin, PPACA mandates a multiple-procedure payment reduction for imaging services performed in a nonhospital setting, such as an imaging center, IDTF, or physician’s office. Though the payment for the professional component is not affected, payment for the technical component will be cut; the technical component of the highest-paying procedure will be paid at 100%, while the technical component for other procedures in the same family will be reduced by 50%. This provision became effective on July 1.Ed Gaines is vice president and chief compliance officer for Medical Management Professionals Inc (MMP), Atlanta, Georgia. Missy Lovell is compliance manager for MMP.