There has been a lot of confusion over the scope of practice and reimbursement of non-physician radiology providers (NPRPs). “Much ire is being wrongly directed toward registered radiologist assistants (RRAs or RAs), whose role is invaluable to us,” according to Catherine J. Everett, MD, MBA, FACR, president and managing partner of Coastal Radiology Associates, PLLC, and a member of the ACR BOC. “People are lashing out at the wrong group of providers.”

The RA’s role is fundamentally different from that of a physician assistant (PA) or a nurse practitioner (NP), for instance, based on their background as an RT and their two years of additional education, says Paul A. Larson, MD, FACR, president of the American Registry of Radiologic Technologists (ARRT) Board of Trustees.

“An RA must work under the supervision of a radiologist and may not interpret imaging studies or prescribe medications or therapies,” Larson explains. “In contrast, PAs and NPs may work with physicians of any specialty and are increasingly obtaining greater independence from physicians — which may include performing, supervising, or interpreting medical imaging.”

RAs are trained through university-based radiologist assistant programs and are certified by the ARRT. In addition to being certified and registered in radiography by the ARRT, candidates must have earned a minimum of a bachelor’s degree (most have a master’s degree) from an accredited educational institution and must complete a preceptorship in which a radiologist mentors the candidate and oversees their clinical education.

Radiologist-Led Teams

“This is the one NPRP group with which we have had continuous positive relations,” says ACR CEO William T. Thorwarth Jr., MD, FACR. “The distinction between RAs and other so-called non-physician extenders is something our members need to acknowledge and appreciate.”

Thorwarth says, “They are purposely named ‘radiologist assistants’ (as opposed to any other name) by design of the organizations representing them. RAs have no intent to practice independently of radiologists — as other NPRPs are attempting — and have been consistent in acknowledging that they should not interpret studies (preliminary, final, or otherwise).” He adds, “There needs to be a mental unlinking of RAs from other NPRPs who are progressively pushing for independent practice.”

“Some radiologists are definitely uninformed about RAs and may have fears based on misinformation,” says Michael Odgren, BS, RPA, RRA, RT(R)(CT), a registered radiologist assistant with Diversified Radiology of Colorado, P.C., and board chair of the American Society of Radiologic Technologists (ASRT). “Recent efforts by other mid-level providers to seek independent practice have fueled that fear.”

“We hear a lot about the radiologist-led team,” Thorwarth says. “We have to understand that a team evolves over time, and our own surveys have shown that up to 50% of radiology practices employ some sort of non-physician radiology providers or extenders.”

While radiologists are leading these teams, reimbursement to radiologists who employ RRAs has lagged behind the real world. “The challenge from day one has been an inability to establish a reimbursement mechanism to the supervising radiologists of RAs for the care in which they participate — despite decades of work with CMS and Congress,” Thorwarth says. “RAs don’t currently provide a CMS reimbursable service. RA patient care needs a fair and proper route to reimbursement.”

MARCA Movement

The Medicare Access to Radiology Care Act (MARCA) was reintroduced earlier this summer at the urging of ASRT, ARRT, and other stakeholders. The legislation would provide reimbursement to radiologists for work performed by RAs as part of a radiologist-led team. The legislative language excludes payment for any independent work by RAs or services provided by any other supervising physician or specialty. “MARCA does not provide for, nor support, independent practice by RRAs or any other NPRP,” emphasizes Howard B. Fleishon, MD, MMM, FACR, chair of the ACR BOC.

“We believe MARCA would ensure that only a radiologist could bill for those procedures performed by an RA,” Odgren says. “It would keep the practice of radiology within radiology teams. It would keep those practices under a radiologist’s control.”

“MARCA is not about RA salaries,” Odgren emphasizes. “The real issue is allowing radiologists the ability to bill CMS for services provided by their RAs. It is also about the survival of the RA profession as part of the radiologist-led team. We want to keep this as a viable career pathway for RTs who are looking to advance their careers and expand their knowledge.”

The distinction between RAs and other so-called non-physician extenders is something our members need to acknowledge.

Perilous Times

Current Medicare billing restrictions are leading radiologists to preferentially hire PAs and NPs — who can bill directly for their work, “despite those practitioners having little if any specific training in imaging procedures,” Larson says.

In addition, PAs and NPs can take what they learn in a radiology practice and work for other physicians, Larson says. “They are increasingly obtaining greater independence from physicians. This is limiting the job market for RAs and decreasing the number of RA educational programs and students,” he adds.

“We have to keep RA programs open and keep these folks working,” Everett says. “When half of radiology practices are using extenders — and the majority of them are PAs and NPs — it is a problem.”

“Number one, you have to train them because they have no radiology training,” Everett says. “Number two, they don’t have to work for the radiologist. They can go work for a neurosurgeon or they can work for an orthopedic surgeon, or even independently in many states.”

“High-quality RTs just don’t want to leave their jobs and invest the time and effort to become RAs when they hear this sort of thing. Our practice keeps our RAs knowing that there may not be a lot more available anytime soon. They know so much and can handle so many things for patients,” Everett says. “The ACR has a responsibility to educate its members about the important work of RAs.”

The RA position was born of a partnership between the ACR, the ASRT, and the ARRT back in 2003 to ensure there is a radiologist-specific mid-level provider. From the outset, the role came with safeguards to ensure control of practice and maintain radiologists’ responsibility for billing.

“The major concern and hesitation I have heard from RTs who are considering becoming an RA is the limited job market,” Odgren says. “I have personally heard from many RTs who say their radiologists would love to have an RA if the radiologists could bill CMS for the RA services,” he says. Instead, there are practices who hire and train other NPRPs without radiology-specific backgrounds. “Even worse, they can seek to practice independently, essentially siphoning off business from a radiology practice,” Odgren says.

Collaborative Commitment

The ACR, the ARRT, and the ASRT continue to work together to ensure consistency in education, scope of practice, and certification standards for RAs. The Society of Radiology Physician Extenders (SRPE) has also joined these efforts as an organization advancing continuing education and professional development for RAs. These groups stand openly and emphatically against attempts of non-physician organizations, including PAs and NPs, to expand their members’ scope of practice in radiology.

“The ARRT, the ASRT, and the SRPE have been consistent, good faith collaborators with us in designing the RA as a profession,” Thorwarth says. “They have looked to the College for input every step of the way to define what radiologists are comfortable having RAs do. That collaboration underlies three principles — that they work only for radiologists, they don’t interpret studies, and are not actively seeking to practice independently.”

“We have these long-term collaborators, but we’ve been challenged by the ability to implement an appropriate payment mechanism for services provided with RRA contribution,” Thorwarth says. “If one accepts the fact that non-physician providers are going to be employed by radiology practices — and many of our members have made that decision — then our focus must be on the type of provider who is best qualified to provide the highest standard of care.”