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CMS’s Deletion of “Purchased Interpretations” Causes Problems for Certain Out-of State teleradiology arrangements: Imaging Centers Billing for out-of-State interpretations can Expect Claim Denials

Effective March 15, 2010, pursuant to CMS’s update to the Medicare Claims Processing Manual addressing “Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti-Markup Payment Limitation”, among other actions, The Centers for Medicare and Medicaid Services (“CMS”) has effectively eliminated an Independent Diagnostic Testing Facility’s (“IDTF’s”) or radiology group’s ability to bill its local carrier (the “MAC”) for interpretations performed by out-of-state physicians (the “CMS Change Request”). Rather, by operation of these Medicare changes and Medicare’s claims processing system, these imaging suppliers must now either take reassignment and bill the MAC in the interpreting physician’s jurisdiction (if and only if they are able to establish a practice location in that MAC jurisdiction for enrollment purposes), or have the interpreting physician bill directly for such services.

Unfortunately, for a substantial number of imaging suppliers (such as radiology groups and IDTFs, which are not subject to the anti-markup rule) that rely upon out-of-state teleradiology arrangements, according to our discussions with senior officials at CMS, until the agency publishes guidance to redress this issue, the only way to ensure payment by CMS of claims associated with these out-of-state interpretation services is to have the interpreting physician bill directly for his/her service. The only other option available for imaging suppliers is to accept reassignment from the out-of-state interpreting physician; however, this will require that the imaging supplier must be eligible to enroll in the out-of-state MAC jurisdiction. Notably, the issue remains unclear whether an imaging supplier will be able to enroll in the other jurisdiction if the supplier does not have a practice location in such jurisdiction. CMS has stated that a supplier without a practice location established in the jurisdiction will not be accepted during the enrollment process. During our discussions with CMS, agency officials indicated that they intend to issue further clarification on these issues. Imaging suppliers whose business operations are adversely affected by this recent CMS Change Request should remain alert for a future guidance on this issue by CMS in the form of another Change Request.

For more information on this issue, please contact Carey F. Kalmowitz, Esq. or Adrienne Dresevic, Esq. at (248) 996-8510, or visit the HLP website.

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