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Developing a Radiology Advisory Committee

Note: In this document, the term radiology or radiologist includes diagnostic and interventional radiology, radiation oncology, nuclear medicine and medical physics.

As the complexity and sophistication of the practice of Radiology has increased over the past ten or fifteen years, so has the importance of maintaining a positive and constructive relationship with all payers. Ask any radiologist about this, and he or she will no doubt have many examples of claims denials because of a lack of understanding in the insurance industry as to how radiologic procedures are performed and how new technology evolves for the patient’s benefit. Even in the Medicare system, problems and difficulties arise at the carrier level when communication between the specialty and the payer is inadequate or nonexistent. The purpose of this communication is to offer suggestions to member radiologists as to how to develop a Radiology Advisory Committee to act as a liaison between the radiology community and the payers to foster effective and valuable communication.

As many radiologists know, Medicare has, by statute, an obligation to meet with the representative physicians from the various specialty societies through the Carrier Advisory Committee, better known as the CAC. Meeting quarterly, the CAC serves as the clearinghouse for the discussion of Medicare policy at the Carrier level, as well as offering a forum for the free and open discussion of other issues concerning payment and provider education. A very successful program, the CAC network is a valuable and effective venue.

Its drawback, of course, is that it is not specialty specific. At the CAC meetings, over twenty-five specialties are represented and there is often little time to accomplish the detailed discussions so often associated with radiology presentations. The non-Medicare payers are under no such mandate to meet with physician representatives and usually have not established Physician Advisory Committees. For these companies, policy decisions are usually channeled through a Medical Director. This director is often an internist or some other type of generalist. He or she is almost never a radiologist, and likely will have little familiarity with new technology and other radiology issues. Thus, it is invaluable to have a Radiology Advisory Committee available to meet periodically with both Medicare and non-Medicare payers.
 
Who should participate?

The model Radiology Advisory Committee should have broad representation from the various radiology subspecialties. At a minimum, it should include a diagnostic radiologist, an interventional radiologist, a radiation oncologist, and a nuclear medicine specialist. It is also absolutely essential that a representative from the Radiology Business Management Association (RBMA) be included. They have the knowledge base and expertise required to ensure that the radiologists and the payer are “speaking the same language.” The term of membership should be long, perhaps indefinitely, so that the payers will come to know the representatives personally and by name.

How often should the Committee meet?

Ideally, the Committee should meet often enough so that issues and problems can be addressed before they become endemic. The frequency should also be often enough so that an identity and rapport will be established between the payer and the Committee. Quarterly meetings seem to be most appropriate. It is best if a regular schedule can be established, for example the third Thursday of January, April, July, and September. Such a schedule can often be difficult to implement because of personnel issues within the various radiology practices and payer related conflicts with other ongoing programs. From a practical standpoint, therefore, it may be best to schedule the next meeting at the conclusion of the current one. This allows for some flexibility in the process while still keeping some momentum. One caution, though. Never leave one meeting without at least a tentative date for the next meeting. These are voluntary meetings for the payer and it is too easy for the entire process to lapse at the least sign of disinterest from the Committee.

How do you motivate the payer to meet with the Committee?

Most payers, believe it or not, want to have a smooth and efficient claims processing system. If a pattern of incorrect policy can be identified, and if specific pertinent examples across the payer’s network can be obtained, then the Committee can serve the purpose of coordinating the identification of the issue without the carrier having to deal with many expensive and time consuming individual appeals. The specific examples can be listed by claim number only, in order that HIPAA related privacy issues can be avoided. The process thus creates focused efficiency, which can be desirable to the payers. 

A significant problem arises when the payer shows no interest in establishing an Advisory Committee. As noted above, Medicare must form and meet with the CAC. A Radiology Advisory Committee, however, is strictly voluntary for both Medicare carriers and non-Medicare payers. They are under no obligation to establish or meet with such a group, and indeed may well be averse to the idea for their own internal reasons.

As such, some diplomacy is required. It is definitely best not to describe the Committee as being designed to “deal with billing problems.” There are always going to be billing problems, and such an approach hints at the adversarial nature of the process. Rather, describe the Committee as informational and educational, sort of a free consultation service for the payer to better understand issues of new technology, practice patterns, sequencing of exams, coding, claims processing, privileging, accreditation and policy development as they apply to radiology. This is something the payers need, and cannot easily obtain. By making relevant presentations to the payer, a line of communication can be established which can serve as a segue into reimbursement issues. The value of portraying the committee as a quality driven, educational resource cannot be overstated.

It is important to be persistent. Even though a payer may be reluctant to begin regular meetings, do not give up. Personnel or management can change, Medical Directors change, and policies change over time. Even if a payer appeared unwelcome to the idea last year, it is possible that new leadership could emerge and the Committee might be better received this year. At a minimum, ACR recommends that the committee send a letter to all the local payers at least once each year and that personal relationships and other connections also be used for the purpose of establishing a liaison. One breakthrough connection can sometimes be leveraged into successful connections with other groups.

What to do when a relationship has been established

After the Committee has been formed and a meeting schedule has been established, preparation is essential. A mutually generated agenda, distributed beforehand, with adequate time allowed for payer and radiology members to form a response, is critical. Payers are busy too and do not want to waste their time or yours in another inefficient meeting. Keep it straight and professional, and do not appear condescending or judgmental. Never forget you are their guest and are there at their discretion. Let them know you realize this and appreciate their time. Never go to one of these meetings without some type of presentation concerning some aspect of radiology, and try to make it interesting and enjoyable. Do not expect a new code and immediate reimbursement for any new technology you present and don’t expect that any issue will be resolved at the time it is first discussed. Do not act disappointed and dismayed if the medical director cancels at the last minute and/or sends a low level subordinate instead.
 That subordinate may well be the future director of policy and you may have an opportunity to cement a valuable future relationship.  Treat everyone at the meeting as if they were senior staff, there is a lot of turnover in this industry and the odds are they will be senior staff someday.  Do not surprise them with new problems that are not on the agenda, no matter how important. Bring them up after the formal part of the meeting is over, even if you need to plan strategically to end the meeting a little early to allow for this informal “off the record” discussion. Try to allow enough time so that you do not have to end the meeting early to rush back to the airport to catch a flight home. Many times the best progress is made after the meeting is over, in a private, more casual situation. Never brag about success or condemn failures. Keep minutes of the meeting, and distribute them promptly both to the committee and the representatives from the payer.

The development of a viable Radiology Advisory Committee is a truly valuable effort and an excellent way to serve the specialty. You will be surprised at what you will learn.

The following outline presents a structural and functional model for a Radiology Advisory Committee. This model is primarily designed for use with non-Medicare payers but can also be adapted for use as an adjunct to the Medicare CAC for more focused discussion of radiology issues.

STRUCTURE

• Co-chairs:  radiologist and payer medical director
• Members:  4-6 radiologists plus RBMA representative
• Subspecialty support network for members
• Payer invited staff:  as needed depending on issues

FUNCTION

• Meeting frequency:  at least quarterly with established schedule
• Agenda:  joint responsibility of co-chairs
• Sample agenda discussion topics:
• Any immediate local issue
• New technology
• Policy development and implementation
• Coding, CPT compliance, bundling, downcoding
• Claims processing – operational issues
• Privileging
• Accreditation
• Prompt payment compliance
• Quality improvement
• Patient access and patient safety

The following list of established Radiology Advisory Committees is provided as a contact resource to further aid members in establishing local committees in their state This list will be updated on a continuing basis.

Radiology Advisory Committees – Contact Resources

THE FLORIDA RADIOLOGICAL SOCIETY INSURANCE LIAISON COMMITTEE

The Florida Radiological Society (FRS) developed an Insurance Liaison Committee almost fifteen years ago to address reimbursement issues and provide educational support for Medicare and third party payors. The Committee has been very successful and continues to try to develop relationships with insurance carriers.

Physician representatives from diagnostic radiology, radiation oncology, nuclear medicine, and invasive radiology staff the committee. The Executive Director and the Associate Director also participate. The RBMA also sends at least three and sometimes four members to the meetings. Members serve indefinite terms; the FRS Executive Committee reviews the roster each year.

Any FRS or RBMA member can submit items for the agenda, and they are collated by the RBMA and submitted in aggregate to the carrier. The carrier receives the agenda well in advance and provides a response to the questions at the meeting. At the carrier’s request, or on the committee’s initiative, a presentation is made at each meeting concerning some aspect of radiology. These presentations usually last about half an hour to an hour. Overall, the meeting lasts two or three hours. Minutes are taken by the RBMA and distributed soon afterwards.

MICHIGAN – COMMITTEE ON THIRD PARTY PAYORS

The Michigan Radiological Society (MRS) chapter of the ACR has enjoyed a long and beneficial relationship with BC/BS of Michigan via its Committee on Third Party Payers.
This committee was established over fifteen (15) years ago in an attempt to work closely with the Blues and establish lines of communication that would be beneficial to both parties.

The committee has a Chair and several members of the Board of the MRS. Every effort is made to represent all types of practice in the State from small to large practices, to academic and community types of practice. While the standing committee has a few constant members over the years, individuals from the radiology community are involved when their areas of expertise are needed to help solve specific issues. The committee gives a report to the Board of MRS at every monthly meeting on activities that have occurred since its last meeting. Using this format, strong relationships between policy makers at the Blues and Physician members of the Board of MRS have been established. There is a bond of confidence and mutual respect that holds the committee together and ensures a continuing strong relationship between both parties.

The predominant role of the committee is to discuss issues that arise on both sides of the table. The most time consuming and most difficult is the area of reimbursement for new technology. The Blues turn to MRS for position statements and ask for scientific literature to support payment for these new procedures. This is a long and arduous task that takes commitment from many physicians in various practices.

In addition, the Blues use the committee to help disseminate information to more than 800 members of the MRS. We have found this to be a very effective way to communicate to our members what the ACR is doing for them.

We often meet with many different departments within the structure of BC/BS. We meet regularly with the Medical Policy division, the physician committee that determines reimbursement guidelines especially for new technology. We also meet with the Audit division to help establish practice guidelines and appropriateness criteria for
radiology practice out in the community. Most recently, we met with the managed care side of BC/BS to discuss utilization review and privileging criteria in private offices.

This Advisory Committee has been a real benefit to the ACR members in the state of Michigan. Much has been accomplished to enhance their practices as well as the care to their patients. The committee is very grateful that BC/BS of Michigan has also found the interaction helpful to determine what is appropriate insurance coverage for the people in Michigan. We encourage other radiological societies to approach their insurance carriers to attempt to establish an Advisory Committee as we have in Michigan.