Developing a Radiology Advisory Committee

The purpose of this communication is to offer suggestions to member radiologists as to how to develop a radiology advisory committee to foster effective communication between the radiology community and payers.

As the complexity and sophistication of the practice of radiology has increased, so has the importance of maintaining a positive and constructive relationship with all payers. Ask any radiologist about this, and he or she will no doubt have many examples of claims denials because of a lack of understanding in the insurance industry as to how radiologic procedures are performed and how new technology evolves for the patient’s benefit. Even in the Medicare system, problems and difficulties arise at the carrier level when communication between the specialty and the payer is inadequate or nonexistent.

Medicare has an obligation to meet with representative physicians from the various specialty societies through the Carrier Advisory Committee, better known as the CAC. Meeting quarterly, the CAC serves as the clearinghouse for the discussion of Medicare policy at the carrier level as well as offering a forum for the free and open discussion of other issues concerning payment and provider education. A very successful program, the CAC network is a valuable and effective venue.

Its drawback, of course, is that it is not specialty-specific. Over 25 specialties are represented at CAC meetings and there is often little time to accomplish the detailed discussions so often associated with radiology presentations. The non-Medicare payers are under no such mandate to meet with physician representatives and usually have not established physician advisory committees. For these companies, policy decisions are usually channeled through a medical director. The director is often a generalist and is almost never a radiologist, and likely will have little familiarity with new technology and other radiology issues. Thus, it is invaluable to have a radiology advisory committee available to meet periodically with both Medicare and non-Medicare payers.

Frequently Asked Questions

How do you motivate the payer to meet with the committee?

Most payers, believe it or not, want to have a smooth and efficient claims-processing system. If a pattern of incorrect policy can be identified, and if specific pertinent examples across the payer’s network can be obtained, then the committee can serve the purpose of coordinating the identification of the issue without the carrier having to deal with many expensive and time-consuming individual appeals. The specific examples can be listed by claim number only to avoid HIPAA-related privacy issues. The process thus creates focused efficiency, which can be desirable to the payers.

A significant problem arises when the payer shows no interest in establishing an advisory committee. As noted above, Medicare must form and meet with the CAC. A radiology advisory committee, however, is strictly voluntary for both Medicare carriers and non-Medicare payers. They are under no obligation to establish or meet with such a group, and indeed may well be averse to the idea for their own reasons.

As such, some diplomacy is required. It is definitely best not to describe the committee as being designed to “deal with billing problems.” There are always going to be billing problems, and such an approach hints at the adversarial nature of the process. Rather, describe the committee as informational and educational, sort of a free consultation service for the payer to better understand issues of new technology, practice patterns, sequencing of exams, coding, claims processing, privileging, accreditation and policy development as they apply to radiology. This is something the payers need and cannot easily obtain. By making relevant presentations to the payer, a line of communication can be established which can serve as a segue into reimbursement issues. The value of portraying the committee as a quality-driven, educational resource cannot be overstated.

It is important to be persistent. Even though a payer may be reluctant to begin regular meetings, do not give up. Even if a payer appeared unwelcome to the idea last year, it is possible that new leadership could emerge and the committee might be better received this year. At a minimum, the ACR recommends that the committee send a letter to local payers at least once a year and that personal relationships and other connections be used to establish a liaison. One breakthrough connection can sometimes be leveraged into successful connections with other groups.

How often should the committee meet?

Ideally, the committee should meet often enough so that issues and problems can be addressed before they become endemic. The frequency should also be often enough so that an identity and rapport will be established between the payer and the committee. Quarterly meetings seem to be most appropriate.

It is best if a regular schedule can be established, for example the third Thursday of January, April, July and September. Such a schedule can often be difficult to implement because of personnel issues within radiology practices and payer-related conflicts with other ongoing programs. From a practical standpoint, it may be best to schedule the next meeting at the conclusion of the current one. This allows for some flexibility in the process while still keeping some momentum.

One caution, though. Never leave one meeting without at least a tentative date for the next meeting. These are voluntary meetings for the payer and it is too easy for the entire process to lapse at the least sign of disinterest from the committee.

What to do when a relationship has been established

Preparation is essential. A mutually generated agenda, distributed beforehand, with adequate time allowed for payer and radiology members to form a response, is critical. Payers are busy too and do not want to waste their time or yours in another inefficient meeting. Keep it straight and professional, and do not appear condescending or judgmental. Never forget you are their guest and are there at their discretion. Let them know you realize this and appreciate their time.

Never go to a meeting without a presentation concerning an aspect of radiology, and try to make it interesting and enjoyable. Do not expect a new code and immediate reimbursement for any new technology you present and don’t expect that any issue will be resolved when first discussed. Do not act disappointed and dismayed if the medical director cancels at the last minute and/or sends a subordinate instead. That subordinate may well be the future director of policy and you may have an opportunity to cement a valuable relationship.

Treat everyone at the meeting as if they were senior staff. Do not surprise them with problems that are not on the agenda, no matter how important. Bring them up after the formal part of the meeting is over, even if you need to plan strategically to end the meeting a little early to allow for this informal “off the record” discussion.

Try to allow enough time so that you do not have to end the meeting early to rush back to the airport to catch a flight home. Many times the best progress is made after the meeting is over, in a private, more casual situation. Never brag about success or condemn failures. Keep minutes of the meeting, and distribute them promptly both to the committee and the payer representatives.

The development of a viable radiology advisory committee is a truly valuable effort and an excellent way to serve the specialty. You will be surprised at what you will learn.

Who should participate?

The model radiology advisory committee should have broad representation from the various radiology subspecialties. At a minimum, it should include a diagnostic radiologist, an interventional radiologist, a radiation oncologist and a nuclear medicine specialist. It is also absolutely essential that a representative from the Radiology Business Management Association be included. They have the knowledge base and expertise required to ensure that the radiologists and the payer are “speaking the same language.” The term of membership should be long, perhaps indefinite, so that the payers will come to know the representatives personally and by name.

How to structure a radiology advisory committee

The following outline presents a structural and functional model for a radiology advisory committee. This model is designed for use with non-Medicare payers but it can be adapted for use as an adjunct to the Medicare CAC for more focused discussion of radiology issues.

STRUCTURE

  • Co-chairs: radiologist and payer medical director
  • Members: 4-6 radiologists plus RBMA representative
  • Subspecialty support network for members
  • Payer invited staff: as needed depending on issues

FUNCTION

  • Meeting frequency: at least quarterly with established schedule
  • Agenda: joint responsibility of co-chairs

Sample discussion topics:

  • Any immediate local issue
  • New technology
  • Policy development and implementation
  • Coding, CPT compliance, bundling, downcoding
  • Claims processing – operational issues
  • Privileging
  • Accreditation
  • Prompt payment compliance
  • Quality improvement 
  • Patient access and patient safety
ACR/RBMA Clinical Decision Support Best Practice Guidelines
Access Guidelines
ACR/RBMA Radiology Benefits Management Programs Best Practices Guidelines
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