Getting Down to Business

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 - Claudette Lew
Claudette Lew, Associate Editor

Healthcare providers are rolling up their sleeves even further and getting down to the business of healthcare. With the final CMS reimbursement decisions made last month and open enrollment in the health insurance exchanges (HIEs) and Medicaid closing next month, there are new data impacting radiology practices. For sure, lower contracted rates from payors and lower reimbursement are on the way—for an extremely large patient population. 

Radiology departments and practices need to revisit the efficiency of their operations. More changes also could be in store to provide some relief if bills to remove the sustainable growth rate (SGR) formula permanently from the calculation of Medicare physician fees are passed by Congress before March 1.  

The impact of HIEs is far reaching and effects everyone from specialist to payor. When CMS releases the final demographic data on HIE enrollees, providers and payors should have a better idea about future utilization rates. For example, older patients often have complex health issues and may require more frequent radiology exams, driving up utilization. Yet, the younger, healthier patient is the demographic profile that was predicted as most likely to enroll in HIE.  The actual patient demographics remain to be seen.

It will be especially critical for radiologists and administrators to pay attention to the trend data derived from HIE demographics to plan for future utilization and revenue changes. As we come into the spring schedule of radiology and healthcare conferences, I look forward to hearing more about and sharing with you the impact of all these changes on radiology, as well as best practices shared for the benefit of continuing to operate successful radiology practices.  

One Congressional bill on the table to reduce the SGR is The SGR Repeal and Medicare Provider Payment Modernization Act of 2014. Among other items, the bill includes a mandate for physicians to utilize appropriate use criteria for imaging procedures, which is much preferred over simply cutting reimbursement; the continuation of meaningful use incentive payments; and requirements to strengthen interoperability between EHRs. The temporary fix to the SGR put in place last year will soon expire and these provisions need to be passed by March 1 to prevent a gap. So far there hasn’t been a determination on how the costs proposed through this bill will be covered. 

Claudette Lew is associate editor of