The Centers for Medicare & Medicaid Services (CMS) do not recognize radiologist assistants (RAs) as independent providers that are billable separately from radiologists, requiring more specialized radiologists to supervise procedures and thereby compelling hospitals to comply with more costly Medicare regulations, according to a study published in the Journal of the American College of Radiology.

“Unlike nurse practitioners and physician assistants, radiologist assistants do not have their own benefit category in the Medicare program and therefore may not enroll and bill the Medicare program for their services,” explained Thomas W. Greeson, JD, MBA, and Paul Pitts, JD, MHA, from Reed Smith (the former in Falls Church, Va., the latter in San Francisco), a law practice specializing in business litigation.

“In other words,” Greeson and Pitts continued, “radiologist assistants are not recognized providers or suppliers for the purposes of payment under the Medicare program. As a result, the services rendered by radiologist assistants are significantly limited by the physician supervision requirements.”

Medicare’s classification and regulation of RAs is nebulous, further complicated by the fact that states’ classifications of RAs, which differ from one another, vary considerably from Medicare’s designations for RAs.

Reimbursement under Medicare for RA procedures varies in requiring the general, direct or personal supervision of a physician, depending on the procedure being performed and the medical setting (inpatient versus outpatient, diagnostic versus surgical) in which the exam is performed.

For example, in the physician office setting, Medicare requires that an RA’s service be “incident to” the service provided by the physician for nondiagnostic testing, including invasive procedures. “For a radiologist assistant’s services to be covered ‘incident to’ the services of a physician, the nondiagnostic testing services must be (1) an integral, although incidental, part of the physician’s professional services; (2) commonly rendered without charge or included in the physician’s bill; (3) of a type that are commonly furnished in physicians’ offices or clinics; and (4) furnished under the physician’s direct supervision,” explained Greeson and Pitts.

What qualifies as “direct supervision” in the office setting? According to the authors, the physician must be present and immediately available in the office suite, able to provide assistance and direction throughout the service. Direct supervision in the surgical or invasive procedure setting, however, does not require that the physician be in the same room as the RA performing the procedure.

“The limitations imposed on billing for the services of radiologist assistants significantly affect the utilization of these professionals at a time when hospitals and radiologists seek opportunities to reduce the cost of healthcare services. These concerns are further compounded by the requirements for personal supervision that apply to many diagnostic tests,” the authors argued.

In 2010 CMS made its requirements for outpatient and inpatient testing and procedures more or less uniform.

Although many hospitals may not completely understand the requirements promulgated by Medicare, hospitals can be subject to overpayment liabilities, requiring recompense to CMS and potential liability for fraud in certain cases. What is more, CMS rules “may create legal liability for a provider who does not personally furnish the service,” as designated by the agency.

CMS has received requests to reconsider its nonconsideration of RAs as independent providers or separately billable professionals. The agency responded in 2010 by saying, “We appreciate the information provided by the commenters as it will assist in understanding the role these individuals play in the provision of imaging services.”

CMS has yet to provide a substantive response to the request, so that supervision levels outlined in the Medicare Physician Fee Schedule remain unchanged.

While recent legislation has increased CMS’ enforcement of fraudulent claims, partly in hopes of increasing savings, the failure of the agency to recognize the important and less costly roles of RAs comes at a time when policymakers are attempting to reign in wasteful spending and tighten the belts of entitlements programs, with Medicare foremost among them.

As the authors noted, “Although hospitals and radiologists may seek to reduce the cost of diagnostic services by expanding the role of radiologist assistants, the limitations imposed on billing for the services they perform negatively affect using the services of these professionals and increases the level of physician involvement in every clinical setting. In this era of heightened scrutiny of claims, radiologists, IDTFs [independent diagnostic testing facilities], and hospitals are more focused on regulatory compliance than reducing cost through the use of radiologist assistants.”

Finally, given the incongruence between Medicare and states’ policies, the authors said it was critical that radiology practices evaluate their protocols regarding RAs and ensure compliance with state and the often more limiting Medicare regulations.