As if radiologists were not facing sufficient challenges of late, they now are seeing increasing interest from cardiologists seeking to promote the sharing of certain studies. In some hospital settings, the cardiologists ask for an exception to the radiologists’ exclusive contract, so that the cardiologists can serve as additional interpreters of such studies as cardiac CT and coronary CTA. Those cases can be approached like other, earlier turf issues, with the radiologists advocating the need to maintain case volumes and expertise within the imaging department. Some institutions will support maintaining radiology for radiologists; where that is not the case, other would-be imagers need to be obligated to follow departmental protocols and share in responsibility for call.

Cardiologists may argue that they are the experts in the heart. Yet while cardiologists do have extensive training, little or none of it has to do with how to operate or interpret CT, MRI, or PET. Indeed, the president of the American College of Cardiologists reported in 2006 that “During most current three-year general cardiology fellowships, achieving level 2 expertise in echocardiography and nuclear cardiology is feasible, but exposure to CT and CMR is incomplete or nonexistent.” Patients are best served by having studies interpreted by an unbiased expert radiologist, someone with extensive training in imaging, and someone whose judgment can’t be colored by the prospect of more tests or procedures. And self-referral is a very real concern as health care costs continue to skyrocket: Between 1993 and 2003, for all sites of service, the utilization rate of all noninvasive imaging per 1,000 Medicare beneficiaries increased 12% among radiologists compared with 170% among cardiologists! The massive growth in utilization by cardiologists has nothing to do with shifts in site of service, but lots to do with self-referral.

Still, more and more frequently, what the cardiologists—sometimes with the backing of a hospital—propose is taking on increasing responsibility for cardiac imaging. Particularly popular at present is an arrangement calling for such studies as cardiac CT and coronary CTA to be interpreted by both a radiologist and a cardiologist. Yet Medicare and other payors generally refuse to pay for two interpretations of what they view as a single study with a single billing code. So how do two different physicians get compensated for the work?

Often, what the cardiologists propose is to split the work, with the cardiologists interpreting only the cardiac portions of the image, and the radiologists expected to interpret the non-cardiac portion of the same image. As for compensation, typically, the cardiologists offer to bill for the entire study, then pay the radiologist for the non-cardiac interpretation—possibly on a percentage basis, more often, by way of a modest flat fee.

This sort of “split interpretation” arrangement raises several difficult legal issues. The difficulties arise out of the fact that current laws and reimbursement conventions do not contemplate that a physician might limit interpretation of a diagnostic imaging study to just one part of the anatomy viewed in the study. Rather, the standard in the industry and standard of care call for a single physician to interpret the entire study. Along these lines, the American College of Radiology has taken the position that a single qualified physician should be responsible for the supervision and interpretation of cardiac CT and coronary CTA exams.

Beyond Turf
Reimbursement is not the only issue raised by such an arrangement. At least as troubling is the question of liability for erroneous diagnosis or failures to adequately inform patients or their treating physicians. Because two separate physician groups are involved, each would likely be named in malpractice litigation and would have to fight over where to lay any blame in the ensuing legal proceedings. Potentially, a physician interpreting only part of a scan could be held responsible for interpreting the entire study, regardless of attempts by the physician or medical group to limit the scope of its interpretation and responsibility.

In other words, the radiology group would likely be pulled into a lawsuit involving a missed diagnosis of the cardiac portion of a CT scan, even though it had tried by contract to limit its work to interpreting the non-cardiac portion. Liability could ensue for a missed diagnosis of the cardiac portion if the radiologist reasonably should have spotted the problem and reported on it. At a minimum, any radiology group contemplating such a shared or split interpretation arrangement should have the proposal reviewed not only by its counsel, but also its malpractice carrier for their views on the subject. Note, further, that if the two physician groups are insured by different malpractice carriers, the complications of any such suit would simply be magnified.

The Medicare fraud and abuse laws present another area of concern if the total fee for the study is being split, as is usually proposed. These proposals usually involve fee-for-service arrangements, which by definition do not meet the safe harbor requirement that a years’ worth of aggregate compensation be determined in advance; they are therefore open to scrutiny. Further, given the nature of the arrangement, it will be difficult to arrive at an objective standard for determining fair market value—a critical element in any defense of kickback allegations.

Finally, some attorneys have asserted that an arrangement such as this will not satisfy the requirements for exemption under the "Stark" law, rules and regulations (including under the pending "Stark III" regulations). This sort of arrangement could lead the cardiologists and radiologists to share more than scans; they could share compliance exposure, as well. And radiologists need to bear in mind that any Stark analysis would involve not only the studies that are being split, but referrals by the cardiologists to the radiologists for other services, regardless of location.

In short, we would prefer to see radiologists avoid arrangements like this. While radiologists may feel business or political pressure to agree to split interpretation arrangements, they should consider carefully the controversy and risks involved. They should realize that payors may challenge what the two physician groups have wrought. And they should also know that an unhappy patient may seek relief from the radiologists, despite any attempt by the physicians to divide up responsibilities by contract.

One approach some have adopted to be as consistent as possible with ACR’s position is to work out an agreement making the cardiologists responsible for interpretation of the whole CT scan, as well as for the written report, supervision of the technical aspects, and maintenance of the equipment. In that approach, the radiologists’ role is to be limited to quality assurance overreads of the non-cardiac portion. (Whether cardiologists or their malpractice carriers are amenable to such an approach remains to be seen). Better still is for the radiologists to educate their communities as to why imaging is best left to the imagers.