September 2021 Ebrief

For this month’s e-Brief, I would like to bring to broader attention a topic that has had heated interest throughout the ACR membership and leadership and which has had spirited discussion on the ACR Engage platform. For those who are not familiar with Engage, it is an online forum hosted at Click Here by the ACR that allows discussion among members on a variety of issues. Discussion is divided into communities, for example, “Body Imaging” or “Medical Physics” or “YPS” to collect members with similar interests. We encourage you to take a look and participate if it catches your interest! On Engage, there have been several recent discussions regarding MARCA (Medicare Access to Radiology Care Act – not to be confused with the quality-metric law MACRA). MARCA is a bill currently sponsored in the House, but without a current sponsor in the Senate. The bill was historically supported by the ACR due to longstanding relationships with the technologists’ professional society, ASRT, as well as other stakeholders, but recent member sentiment raising concerns about MARCA culminated in an organized ACR town hall on August 17, 2021, to allow commentary and debate on the subject. The recorded town hall is available at: Click Here

One of the most-discussed issues within MARCA is the proposed ability of Registered Radiology Assistants (RRAs) to bill Medicare incidents to a radiologist at 85% of the fee schedule, under “direct” supervision rather than “personal” supervision. When Medicare requires “personal” supervision, as for a fluoroscopy study, that means “in the room” or “at the elbow” of the midlevel extender. Currently, RRAs operate with “personal” supervision – the radiologist can bill 100% of the Medicare fee because the radiologist is at the side of the RRA while the procedure is being performed. MARCA proposes “direct” supervision, which is confusingly named. “Direct” supervision means the radiologist is within the radiology suite or hospital, but not alongside the RRA. When direct supervision is being performed, radiologist bills at 85% of the Medicare fee schedule. This is what happens when a PA or NP acts as a midlevel – the supervising physician (whether a radiologist or an orthopedist) is providing direct supervision and billing occurs either as a physician or directly as PA/NP at 85%. MARCA proposes a similar pattern for RRAs, allowing direct supervision at 85% billing, but also requiring that billing be “incident to” a radiologist. That is, with the law’s current wording the RRA cannot bill at 85% independently. This would allow RRAs to provide services for radiologists similar to what PAs and NPs can currently provide. According to the ACR town hall, there are currently approximately 500,000 PAs and NPs in the US, and less than 1000 RRAs: the current asymmetry in billing has been implicated in the slower uptake of RRAs as extenders.

The August 17th town hall provided speakers discussing the pro, con, and neutral positions on the subject. Matthew Johnson, an academic Interventional Radiologist at Indiana University, provided a more extended “pro” position for the town hall, and Kurt Schoppe, a private practice radiologist from Radiology Associates of North Texas, provided a more extended “con” position. Q and A was taken verbally and via Zoom chat. Points for the “pro” position included: protecting an extender position with restrictions on practice and the requirement to work under a radiologist (unlike PAs and NPs), supporting colleagues at ASRT who advocate for RRAs, and helping radiologists who currently use RRAs to be able to bill for them with direct supervision. Points for the “con” position included: avoiding an extender who is uniquely radiology-trained and could potentially displace radiologists, forestalling scope creep and desire for independent practice, and favoring physicians and their trainees’ being more directly involved in patient care rather than extenders.