Practice Management

Hi Julie

When you say new laws, are you referring to the No Surprises Act?  If that's the case, unless your old rates were exceptionally high compared to the majority of radiologists in your market, the NSA should not lead to a rate cut for hospital-based radiologists, or at least they should think carefully before accepting it.

Under the NSA, if a radiologist is out of network for a service rendered at a contracted hospital, the patient must receive in-network benefits, based on the Qualifying Payment Amount (QPA).  The QPA is defined as the January 31, 2019 median contracted rate for the same service, same payor and same specialty in the same market, adjusted annually based on CPI-U.  The 2024 adjustment yields a QPA that is the January 2019 median plus ~ 20.9%.

If you're a hospital based radiology group working at an in network hospital, you will get the January 2019 median plus 20.9% plus a CPI based adjustment annually every year into the future, and the patients will get in network benefits.  I would think about that compared that to the proposal.

Now, having said all of that, if you actually go out of network, you should be prepared to navigate the open negotiation and Independent Dispute Resolution processes, which does involve some headaches, but can be worthwhile if the end game is a better contract with a major payor.  One other caution is that there are proposed rules that would significantly change the IDR process.  If those rules are finalized, especially the proposed limitations on batch disputes, it could significantly impair the value of the IDR process for many radiologists and potentially make going out of network less attractive.  Hopefully CMS will heed RBMA's comments on this topic.

I hope this is helpful.

       David Smith, FACMPE  |  Executive Director  |  913.444.9359

5800 Foxridge Dr.  Ste 240  |  Mission, KS  66202  |  www.uickc.com

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