Radiologists considering the use of an outside service for final reads will have questions that include not only quality and cost but also the impact on the group’s relationship with its hospital and referring physician community. The answer will not be the same for every radiology practice.  Here we present some of the pros and cons for consideration in the decision-making process.

The teleradiology industry was founded well over a decade ago around the idea that a radiologist in a different time zone could handle a practice’s overnight hospital emergency readings and allow the local group to avoid that dreaded shift. Those preliminary readings would have to be over-read by the local group the next morning in order for them to issue a final report.  Today the original idea of providing only preliminary reads for night coverage is becoming outmoded, and modern teleradiology means real-time, final reporting from a remote site.

Why Use A Teleradiology Service?

There are many reasons why a radiology practice would want to hire an outside teleradiology service in addition to the overnight coverage, which is still one primary motive. For example, teleradiology can provide sub-specialty expertise to enhance the quality of a practice that might not need a full-time specialist, or provide coverage for vacations or other gaps in a group’s regular staffing.  Groups might have difficulty hiring a new full-time radiologist who brings the right combination of cultural fit and skill set, so they might use a service until the appropriate candidate comes along.  

The benefit to the radiology group is easy to see, but the radiologists might fear being replaced by an outside service if the hospital sees the service as a more cost-effective option, or one that can provide radiology coverage with faster turnaround time. This is why it’s important for the radiology group to work with the hospital administration so that everyone is on the same page about why the outside service is being used.  For example, the availability of sub-specialty interpretations overnight will be a real enhancement to the hospital.  The hospital will benefit from this expertise, while maintaining its local team of dedicated, valued radiologists.

Will Our Quality Suffer?

A concern of both the radiology group and the hospital will be the quality of the teleradiology service.   The teleradiology physicians can and should be held to the same standards of quality as the local radiology group when they are providing final rather than preliminary readings. Before agreeing to bring on a service, the radiology group should review the qualifications of the physicians who will work on their account.  Be sure to obtain the right to approve or disapprove any physician for your panel as part of the written contract. In addition, the group should obtain a sample set of reports from the teleradiology service in order to assess the quality of their work.  If the practice is using standardized reports or macros, the teleradiology service should conform to them.

The service’s physicians must assure compliance and provide documentation to support it. This becomes especially important as groups are considering their participation in the Medicare Incentive-based Payment System (MIPS). Each of the teleradiology physicians will have to comply with the MIPS reporting standards as regular members of the group practice.  For example, proper reporting of incidental findings and recommendations for follow-up under the Quality Category of MIPS will have to be part of their regular review and reporting.  Aside from Quality reporting, the addition of a number of remote readers (who are counted as regular group members) might put a small group of local radiologists into the category of a larger practice for MIPS if the addition of the offsite doctors brings their total to greater than 15 physicians.  This will impact the group’s level of reporting for Improvement Activities. 

Do the Benefits Outweigh the Costs?

The cost/benefit analysis of using a teleradiology service involves several factors, and there might be good reasons to have an outside service provide final readings for all or part of the practice’s work that supersede the overt results of such an analysis. The benefit afforded by having sub-specialty expertise, for example, could be very valuable to the group and outweigh the cost, even if the group loses money on certain individual exams.   Another potential benefit is elimination of the time and related opportunity cost for a local radiologist to perform a final read following a preliminary review.  The higher cost of a final reading can be offset by the productivity gained when the local radiologist can perform more profitable work.

Some of the costs associated with establishing this type of relationship are easily measured, while others are less obvious. Here are the major cost components of the financial analysis the group has to consider:

• Whether considering the service for preliminary or final reading, the first basic step in the cost/benefit analysis is to review the types and number of images you expect the service to read, and estimate the amount of revenue these will generate. Compare this potential revenue with the cost of the service. Look carefully at how the teleradiology service charges your practice for the images it reads as compared with the way the same exams can be billed out. For example, the billing for certain services might be bundled into one CPT code (e.g., CT abdomen and pelvis) while the service might charge for reviewing two images.
  
  
• The cost of credentialing with the hospital cannot be overlooked since each remote physician will have to be credentialed with the local hospital’s medical staff in order to provide services for the hospital’s patients. The medical staff fees and administrative effort required for onboarding these physicians could quickly add up to a significant amount. The number of radiologists assigned to the group is important and can be addressed in the contract with the teleradiology service. The cost can be a shared responsibility between the group and the service. Typically, once the agreed upon level of physicians is reached, any new credentialing costs attributed to the service’s staff turnover should be their own responsibility.
  
  
• Medicare rules dictate that the billing for the final interpretation has to be sent to the Medicare carrier in the locality where the reading service takes place, and the reading cannot take place outside the United States. This means that radiology groups must ensure their systems are set up to identify where the reading has taken place. The number of states and localities involved in the pool of offsite radiologists should be managed through the contract, because there is a cost associated with enrolling and credentialing the remote radiologists in each billing locality where claims have to be sent. Of course, the reading radiologists must be licensed in the various states where they are practicing.
  
  
• The cost of insurance credentialing is real, whether it is undertaken by in-house staff or the practice’s outside revenue cycle management (RCM) vendor. Often the RCM vendor will provide a discount for a large volume of credentialing, but the cost of this service must be factored into the overall evaluation of the cost of the teleradiology service.  Be sure the volume of work required to credential the remote radiologists can be absorbed, whether by in-house staff or by the RCM vendor, before proceeding with the contract.
  
  
• An imaging center that uses offsite final reading will have to split the technical component (which is sent to the locality where the center is located) from the professional component (which is sent to the locality where the radiologist performs the reading) for Medicare patients. There might be a cost for systems modifications since the imaging center usually sends a single, global claim for its services.

Periodic monitoring of the relationship includes review of the outside service’s invoicing. One practice  sampled 300 cases in one month and found that over 50% of them cost the group more than the reimbursement for those procedures, resulting in a deficit of $1,000 that month.

Conclusion

Federal and state regulations that affect the billing and licensure considerations discussed above are constantly changing, and so the radiology practice will have to be sure it is up to date on all of the rules before and during a teleradiology relationship. It is also a good idea for the group to update their team of remote readers whenever practice policies or procedures change.

The decision to use a teleradiology company for final reading rather than for preliminary reading takes some careful consideration. Having only a preliminary reading is less efficient, because the local group has to handle the images twice.  This method also bears a certain additional cost, because the local radiologist has to spend time with the over-reading when he or she could be more productive with other services.  However, when theteleradiology service is providing final reads the fee charged will be higher due to their increased risk and more detailed reporting requirements.  This higher fee, coupled with the increased cost to bill for final readings that take place in localities outside of the main practice location, will have to be weighed when considering the value the final reading brings to the group.

Recent Articles

Best Practices in Radiology Patient Billing
Exempt from MIPS? Think Again About Participating as a Group
An Update for Radiologists on Approriate Use Criteria and Clinical Decision Support