William,
You seem well acquainted with the rules, but please allow me to review some of them for discussion purposes, and then I'll express some personal opinions.
CMS rules requiring a physician to be immediately available for all procedures requiring Direct Supervision, which covers any study during which IV contrast is injected. Gad is an IV contrast and therefore falls into this category. Direct Supervision can only be provided by an M.D. or D.O. - PA's and NPs can't provide the supervision. Generally speaking, any M.D. or D.O. can provide it. Having said that, some Medicare Administrative Contractors have established policies for IDTFs that only allow Radiologists to provide the supervision, and will not allow non-rads to provide it. That is within their purview. I've not heard of MACs limiting supervision to rads in non-IDTFs (i.e., physician offices), but I've not really taken the time to research it, either. On a related note, I personally always extended Medicare rules to to all government payers when establishing our practice's compliance policies, which mean that we applied Medicare rules to Medicaid, TriCare, etc.
Over the years there have been several imaging centers and physicians caught not complying with the contrast supervision rules and getting into very serious legal trouble with the OIG. Obviously, you simply must provide direct supervision for your Medicare patients (and other patients covered by a government plan).
Commercially insured patients are another matter, at least in theory. You'd first need to check your state's laws. Iowa, for example, does not require Direct Supervision for contrast studies by statute. This means that, technically, facilities can inject contrast without having a physician present.
Our practice rejected injecting commercially-insured patients with an IV contrast (including Gad) without physician supervision, feeling that, while arguably legal, it was simply poor practice to do so. Others are free to come to a different conclusion. I know of one such MRI facility (no longer in business) that operated in that manner. I'd only caution that those that do this should explore their motivation for practicing medicine in this manner.
On a related note, if I was a competitor in your market and learned this was standard practice at your facility, I'd market the heck out the fact that you don't provide physician coverage for contrast injections to the referring physician community as well as to the commercial payers directly. One can argue all day long the risk is low, but good luck with that. Don't think for a moment others wouldn't learn of this practice.
I suppose the industry could try to convince CMS to change its supervision rule for Gadolinium. There is not a snowball's chance in h### of success. One only needs to read Dotarem's package insert, which reads in part, to see why:
----------------- WARNINGS AND PRECAUTIONS -----------------
• Hypersensitivity: Anaphylactoid/anaphylactic reactions with cardiovascular, respiratory or cutaneous manifestations, ranging from mild to severe, including death, have uncommonly occurred. Monitor patients closely for need of emergency cardiorespiratory support.
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With any published risk of death there is simply no way CMS is going to change this rule. Arguing that the physician is merely going to call the EMT's anyway won't get far. Frankly, I seriously doubt the ACR would support the change. IMHO, since this is a clinical issue, the RBMA has no business making that argument. It can't be about saving money.
My suggestion to you is to try to find a less expensive way of hiring physician supervision. For example, can you hire Family Practice residents from a nearby program to come to your facility to sit there? They're licensed doctors and may appreciate the added income. I'm sure there are other creative ways to find an acceptable solution.
Sincerely,