Practice Management

David,

You can read remotely if the rads are billing for the PC themselves for Medicare (we extend this to Medicaid).  You must read onsite if you've reassigned payment to the ortho group and they bill and collect.

In our case, we read remotely and file the claims ourselves for the professional component for all Medicare and Medicaid patients, but the ortho group files the claims for all studies whose claims are filed with commercial insurers. 

I had the same question a few months ago.

Obviously if they're not enrolled as an IDTF and you are split billing, the liability for supervision resides with provider billing the TC.

Weighing in on the issue of referring physicians billing Medicare for remote reads of in-office radiology studies they self-refer. Some comments relating to Stark and the anti-markup rule:

·         When radiologists provide interpretation services for a referring physician group, if the referring physician group bills Medicare for the remotely-read interpretation service for tests their shareholders order/refer, Stark and the anti-markup rule come into play. The interpretation service is a designated health service, and referrals to a shareholder physician's group practice trigger the need for Stark compliance.

·         Stark's "physician services" exception mandates that such interpretation service be provided by the independent contractor radiologist (a "physician in the group practice" in Stark parlance) on the group practice's premises if the group chooses to bill the PC service without treating it as an anti-markup test.

·         Billing the remotely-provided interpretation service as an anti-markup test is an exception to the Stark rules . But if the referring physician group does not want to bill a remote interpretation service to Medicare as an anti-markup test, it should be billed separately by the radiologists.

·         Billing the remote read by the referring physician group requires the group to identify the PC service as an anti-markup test, indicate on the 1500 remittance who read the study and the cost to the group for the interpretation service.

These rules apply only to Medicare patients. The referring physician group can contract with the radiologists to perform the interpretations for their in-office imaging on non-Medicare (traditional Part B) patients, pay the radiologists on a FMV basis and bill globally to private payer and even other governmental plans.

Thomas W. Greeson
703.641.4242
tgreeson@reedsmith.com

Reed Smith LLP
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McLean, VA 22102
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Thank you Thomas for your response!

Based on your comments, could you let me know if the below type or arrangement would be okay or not for Medicare patients? If not, what would have to change to be in adherence to Stark and the anti-markup rules:

1. Independent hospital radiology group reads MR's remotely for scans done at a local Ortho group. The Ortho group does refer patients to the hospital that the radiology group provides the PC.  No radiologist is on site at the Ortho Group.
2. The ortho group bills globally
3. The ortho group pays the radiology group per scan based on a blended rate per exam.
4. The blended rate is above Medicare allowables for most CPT's. However, it is below a few low volume CPT's
5. However, as a whole the Ortho group pays the radiology group more than the respective Medicare allowables applied to all CPT's that are read.