Medicare Compliance & Reimbursement

Doctors may need to restructure payment arrangements soon.

If the Centers for Medicare and Medicaid Services adds diagnostic nuclear medicine and PET scans to the list of services covered by the Stark self-referral law, then doctors will have to apply a stricter set of rules to those services, according to experts.

Many observers have been expecting CMS to add diagnostic nuclear medicine and PET scans to the Stark list for a while, according to Washington, DC attorney Kevin McAneney.

"They basically went back and decided that imaging was imaging," whether it was an ultrasound or a PET scan, he says. McAneney helped write the Stark regulations when he worked at the HHS Office of Inspector General.

But since providers already have been living with those rules for ultrasounds, CT scans, X-rays and other imaging tests, complying with those rules for PET scans and nuclear medicine won't be an impossible task, says McAneney. The Stark law just adds "certain constraints," he notes. Interpreter Must Be In-Office If CMS' proposal becomes final and a physician wants to continue providing diagnostic nuclear medicine, then she'll have to fit the ventures into a safe harbor, explains Barbara Grant, a principal with Gates, Moore and Company in Atlanta.
The biggest safe harbor is probably the "in-office ancillary services exception," which allows physicians to provide services in their office if they meet certain requirements. Not only would the nuclear medicine equipment have to be in the office where you treat patients, but the person who interprets the test results would have to be in your office as well, notes attorney Alice Gosfield with Alice Gosfield & Associates in Philadelphia, PA.

Under the Stark rule, a physician would have to provide the services in an office where she also examines patients. And in a group practice, individual physicians couldn't receive payments based on the number of nuclear medicine tests they ordered. Instead, physicians would have to receive an equal share of the profits from nuclear medicine tests. Or they could receive a share based on their proportion of total income, not just income from nuclear medicine.

"If a group already has a nuclear med camera and provides nuclear med services, it's a highly unlikely option that they would refer it out, because the easy alternative is just change your compensation formula," says Grant.

Cardiologists would be among the hardest hit by the change, says Grant. Cardiologists perform a lot of diagnostic nuclear medicine and often have their own equipment. They're in a position to order nuclear medicine tests, so they've invested in being able to provide the tests themselves.

The CMS proposal mentions that the agency might grandfather existing arrangements for diagnostic nuclear medicine, notes McAnaney. "That's basically unnecessary and unwarranted," he insists, [...]