How absentee radiologists can suck the financial blood from an EP’s work

WARNING:  If you are a radiologist, married to a radiologist, related to a radiologist, or even remotely like radiologists, you will be offended by this article. Be forewarned.

I attended the Gorgas’ School of Tropical Medicine in Lima, Peru.  We were treated to a wealth of clinical material including all types of worms, amoeba, malaria, fungal infections and more blood-sucking, vector-driven infectious diseases than you can shake a stick at. Subsequently, I have been asked many times “What is the most horrific parasite you have ever seen?” Those asking the question always expect to hear about some invasive, caseating, nasty infection with terrible suffering and awful consequences. However, I always respond that the worst parasite I have ever seen is a radiologist arriving at the hospital Monday morning in a black German-made luxury car (think vector here). 

Upon entry to the hospital these parasites will commence to feed on the financial juices of the lowly unfortunate EPs, who had to work the entire weekend without radiologic support or back up, particularly for the plain films they ordered. The radiologist arrives well rested, café latte in hand, and promptly installs himself in a dark room to re-read and bill for all the films the EPs read over the weekend. These same radiologists that are getting wealthy from re-reading films on ED patients long since discharged home do not understand why we do not welcome their belated input. 

With regards to radiology, never has a specialty done so little for so many and been paid so much.  Added to each read is “Recommend clinical correlation” or perhaps a self-referral like “MRI recommended” to clarify the pathology which we have already dealt with, contributing nothing to the outcome but cost.

The bills submitted for non-contemporaneous readings by radiologists are an enormous fraud occurring across the country at almost every hospital on most mornings, especially Mondays. Why does “the system” tolerate it? Where is CMS – or any of the other regulatory behemoths such as the Joint Commission, who are supposedly concerned with waste, fraud and abuse? Nationwide, the billings for these non-contemporaneous to care readings is millions of dollars a year.  

In California it is estimated that each EP provides approximately $150,000 per year of uncompensated care as part of our EMTALA obligation. I am proud of the fact that we provide this safety net.  However, as third party payers continue to down code and bundle our services, and balance billing comes under prohibition state by state, I want to be paid for these interpretive services which I render without radiologic support. I will be the one sued for missing the fracture, why shouldn’t I be paid for reading the film?

How much are these plain film interpretive services worth? In a study of a single hospital in Southern California with a modest payer mix, the plain film interpretive services worked out to $19 per EM clinical hour worked. This number comes from actual reimbursement data at a hospital where the radiologists are appropriately forbidden from billing for non-contemporaneous plain film readings. 

If you multiply that hourly rate for 140 clinical hours per month, it is $1660 or about $19,000 per year for every full time EP at the site.  Obviously, this EP group had to have the unmitigated gall to claim this income as well as the political power to stop the radiologists from submitting bills for those plain films which they were not reading contemporaneously.  For many of you reading this, that battle might threaten your contract or result in other serious problems within your hospital, so you have decided to let sleeping dogs lie (or using the parasite analogy, you have left the feeding tick undisturbed).  I would suggest that becoming a “whistle blower” would be appropriate here.

In December of 2009 CMS again made it clear that contemporaneous service matters.

Billers of diagnostic and interpretive studies are required to use only the date when the interpretation was performed as their service date and not the date the film was taken. The instruction from the Medicare Carrier Manual is as follows: 

10.6.3 - Date of Service (DOS) Instructions for the Interpretation and Technical Component of Diagnostic Tests (Rev. 1873, Issued: 12-11-09, Effective: 01-04-10, Implementation: 07-01-10)

The appropriate DOS for the professional component is the actual calendar date that the interpretation was performed. For example, if the test or technical component was performed on April 30th and the interpretation was read on May 2nd, the actual calendar date or DOS for the performance of the test is April 30th and the actual calendar date or DOS for the interpretation or read of the test is May 2nd.

The practical argument from radiologists has always been that, if the emergency physician (EP) bills, the radiologist’s claim will be rejected. Radiology billers have demanded the right to report the film date so that their bill matches the hospital’s bill.  But now, there is no doubt about the correct date of service – the date the interpretation was made.  

As a result of this instruction, what we have claimed to be true for a long time is now clear. It is effectively a fraudulent claim if a physician falsifies the date of service in order to effect payment. You might even begin to see the black Porsche in the parking lot on Saturday mornings as the radiologists begin to claim that they were right by your side at 3 am on Saturday night after you got that post-intubation chest X-ray on the intoxicated motor vehicle accident victim with a head bleed.

As Greg Henry MD, past-president of ACEP, has pointed out when discussing medical economics, the pie isn’t going to get bigger. The only question is “How big is your slice?” If you feel you deserve more of the pie, then someone else will consequently get less. Our slice should be bigger, and the fraudulent radiology slice can get smaller. If this is bitter sounding to radiologists then the pie can be key lime pie with lemon zest on top. Either that or they can begin to learn what being at the hospital feels like on nights, weekends, and holidays. I am tired of supporting their relaxed lifestyle and making car payments on their Porsches. We all know they will not adopt our lifestyle, so they need to give up the dollars and eat less pie.

At academic centers with radiology residents, the fraudulent behavior is on multiple levels. The radiology attending supposedly supervising residents at night are often not doing so. Therefore, the bill submitted by the radiology attending for the reading of a film days after ED discharge is fraudulent to the third party payor as well as to the university. Furthermore, they are educating young radiologists regarding the responsibility and ethics of their specialty. What they are teaching them is that the radiologists’ clinical contribution and interpretive services should never get in the way of their radiology lifestyle. Sure the radiology resident can stay up all night, but not the attending.

It is time to break the vicious radiology parasitic life cycle. This cycle has a vector (Porsche or any black German car), an incidental host (the ED), a nest egg component (pick the gated community where they live or the vacation home they have in Aspen), and a feeding stage (sequestered in the darkness of a reading room). So spread some albendazole around the reading room and stop this epidemic. Blow your whistle loudly. Get paid for interpreting the films you read last Saturday night. It’s so easy in fact that you’re already doing it! It will feel really good to get paid for it.

You deserve it.  

Dr. William Mallon is an associate professor of clinical emergency medicine at the Keck School of Medicine of USC. He is also the director of the Division of International Emergency Medicine, LAC+USC Med Center.