Recently, a New Jersey court handed down a decision that could potential change the role radiologists play when it comes to determining the medical necessity of a study ordered by a referring physician.
Although the current ruling only applies to New Jersey radiologists, industry experts are talking about how it could possibly affect your responsibilities, daily work flow, and liabilities.
Allstate Insurance brought suit against radiologists who conducted MRIs and X-rays on patients who had submitted personal injury claims. The company argued the providers had not completed their due diligence in checking into whether these studies were warranted, suing to recoup $200,000 of expenditures.
Company lawyers asserted the radiologists were the imaging center’s medical directors and, therefore, bore the responsibility of verifying medical necessity. The radiologists countered that the chiropractors and other referring physicians who send them patients satisfy the state’s requirement of being “verified” providers. But, the judge ultimately ruled the onus of ensuring proper clinical evidence exists to support medical necessity and appropriateness lies with the radiologist.
According to Greg Nicola, MD, treasurer of the Radiological Society of New Jersey, the organization is filing an appeal of the ruling. The American College of Radiology (ACR) also considers the case to be unique – one that will likely only bind New Jersey radiologists, said Tom Hoffman, JD, the ACR’s associate general counsel.
“The lesson remains to realize that the radiologists aren’t in the driver’s seat about medical necessity decisions because they don’t interact daily with the patient,” Hoffman said. “They’re hard pressed to have all the sufficient clinical background on a patient.”
Impact on Your Daily Work
The specter of having to double-check behind your referring physicians to ensure they’re ordering proper studies can be daunting, Nicola said. In most cases, if a provider sends a study order, accompanied by either an ICD-9 or ICD-10 code, you likely assume there’s sufficient medical evidence in each case. Adding another layer to the process could slow your work flow to a slog.
“I don’t think we could do it – there are so many studies to do in a day,” he said. “If we have to validate every prescription – either with the patient or the doctor – that would be very difficult.”
But, before you worry too much, he said, you’re likely already taking steps to validate the medical necessity of nearly every study that comes into your imaging center. By having patients fill out forms and questionnaires that ask for the reasons behind their clinical visit and request for a study, you’ll have official documentation of medical necessity. For example, any patient who comes in for an MRI of the lower back can explain their experience with possible long-term back pain.
Unfortunately, emergency departments and hospital inpatient settings don’t have the resources available to disseminate and gather these forms, and in many cases, patients aren’t able to fill them out.
But, if you do have questions, Nicola said, don’t shy away from giving the referring physician a quick phone call to verify why he or she has ordered the study. And, if you disagree, offer your expert opinion. When you can, he said, make all calls to referring providers at least a day before you’re expected to perform the study.
“Always reach out to your referring physicians in the community,” he said. “Don’t ever be intimidated to do so. It helps keep the lines of communication open.
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