New Rules of the Game: Medical Directors Assume the Quality Burden

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Demand for radiologists acting as medical directors could jump if a proposed regulation now under consideration by CMS is adopted. The proposed rule would require all nonhospital providers of imaging services to meet Medicare’s existing requirements for IDTFs, which specify that there must be a qualified physician designated to supervise care and the ongoing use of the imaging equipment.

Thomas W. Greeson, JD

Since, under the current rules, only radiologists are deemed sufficiently qualified to perform such supervision, every cardiologist, urologist, orthopedist, or other nonradiologist with in-office advanced imaging capabilities might be compelled to partner in some fashion with a radiologist, and to name that imaging specialist as medical director if and when the proposed new rule goes into effect, according to Thomas W. Greeson, JD, health care attorney and former ACR general counsel .

“CMS refers to the role of medical director at IDTFs as the general supervising physician and defines that doctor as one who is proficient both with the facility’s imaging technology and with the interpretation of the studies generated by that technology.”
—Thomas W. Greeson, JD

Overall, the growing demand for quality and accreditation by payors and hospitals is placing a new burden on radiology practices, and some are responding with increased responsibilities for the medical director, with newly created quality positions in the practice, and with a call for compensation in the hospital setting.

Call for Accreditation

Even without the contemplated CMS rule, Greeson suggests that it is undeniable that the role of medical director in radiology environments is growing in importance. The biggest driver, at the moment, is the call for imaging providers to be accredited as a precondition for winning contracts and securing reimbursement from third-party payors.

Greeson, who also is a partner in the Falls Church, Va, office of Reed Smith LLP, says, “As just one of many examples, UnitedHealthcare is putting in place a requirement, effective in the fourth quarter of 2009, that all of its outpatient providers of advanced imaging—MRI, PET, CT, and nuclear medicine—be accredited either by the ACR or the Intersociety Commission for Accreditation. The key requirement, such as that being crafted by UnitedHealthcare and others, is that accreditation hinges on the technical-component imaging services being under the supervision and direction of a board-certified radiologist.”

Greeson notes that accrediting bodies like the Joint Commission have historically insisted on radiology medical direction in hospital settings, much as CMS has for IDTFs. Payors also have sought to define the scope of the role played by the radiology medical director more carefully, Greeson adds. Medicare, for instance, came out with a rule two years ago limiting the general supervising physician of an IDTF to being responsible for no more than three such enterprises at a time. “This was aimed at preventing the general supervising physician from becoming stretched so thin that he or she would be unable to have real interaction with the mechanisms and processes for assuring quality,” he says.

Indeed, the goal of quality assurance (QA) is at the very heart of the medical director’s role. “The medical director works hand in glove with the radiology department’s administrative director or the chief technologist to see to it that all of the imaging equipment is performing appropriately and that the technologists are performing well,” Greeson says. “It should be remembered, however, that the medical director does not have an administrative responsibility: He or she is not hiring and firing the technologists, for instance. What he or she does have is oversight of the quality of radiologic technologists, and that means he or she should be involved in reviewing their performance evaluations and having input into that process.”

Moreover, Greeson says, the medical director should be involved in the medical/radiological physicist’s review of equipment and be the one to sign off on it. “The equipment must be documented to produce quality images,” he explains. “Without that assurance of quality images, the interpretation may not be as effective.”

Misleading Title

Alan Kaye, MD, FACR

To some, the title of medical director is a misnomer. One who hews to that opinion is Alan Kaye, MD, FACR, president of Connecticut-based Advanced Radiology Consultants and chair of the