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September 20, 1995

Responses to a Payment Policy Denying Professional Charges for Diagnostic Imaging by Nonradiologist Physicians

Author Affiliations

From the Department of Radiology, the University of Virginia, Charlottesville (Dr Hillman); FIRST HEALTH Strategies Inc, Pittsburgh, Pa (Mr Olson and Ms Colbert); and the United Mine Workers of America Health and Retirement Funds, Washington, DC (Mr Bernhardt).

JAMA. 1995;274(11):885-887. doi:10.1001/jama.1995.03530110047034

Objective.  —To assess the impact of a payment policy denying reimbursement for the imaging-related professional services of nonradiologist physicians by comparing the use of and expenditures for diagnostic imaging examinations before and after implementation of the policy.

Design.  —Retrospective economic evaluation of claims and expenditures for diagnostic imaging examinations filed by physicians practicing in the 20 US counties having the greatest number of United Mine Workers of America Health and Retirement Funds (hereafter referred to as Funds) beneficiaries.

Setting.  —Insurance claims database of Funds beneficiaries, most of whom are elderly and live in rural communities and small towns.

Intervention.  —The January 1,1993, implementation of a reimbursement policy denying payment of professional claims for diagnostic imaging of nonradiologist physicians.

Main Outcome Measures.  —Numbers and types of eligible claims and Funds payments for diagnostic imaging examinations during the year before and after the intervention, normalized for changes in the number of beneficiaries.

Results.  —Despite the rejection of $811 466 in claims disallowed by the policy, the Funds paid 12% more for diagnostic imaging performed in the 20 counties we studied during 1993 than during 1992. The Funds reimbursed 41% more claims per beneficiary for diagnostic imaging in 1993 than in 1992 (t=-8.03, P<.0001). The absolute number of professional claims per beneficiary increased more than did technical or global claims.

Conclusions.  —Despite a payment policy designed, in part, to reduce the Funds' imaging-related expenditures, the physicians we studied filed more claims, leading to greater expenditures. An increased number of self-referred technical claims and greater referral to hospital radiology departments likely account for most of the observed increases in utilization and costs.(JAMA. 1995;274:885-887)