The Value of Onsite Ancillary Imaging

In today's medical practice environment where quality, patient care, cost and profitability are critical factors for success, physicians and practice managers are looking for different ways to deliver new and existing services to enhance practice performance and offer more value to patients. While there is no one silver bullet to improve performance, medical practices are investigating the service and economic benefits of onsite imaging.  Many have chosen to adopt onsite ultrasound imaging for the advantages offered to their practices and patients.

Here are five ways that on-site diagnostic ultrasound service may benefit medical practices in the areas of profitability, patient care, patient compliance, office staff convenience, physician control and patient cost.

1. Increase practice revenue and profitability: Stop referring valuable revenue out the door. The referral of imaging outside of the primary care environment to a hospital or other imaging center is common practice for many medical groups.  In some instances, this referral pattern provides the best option for the medical practice and patient. However, clinicians adhering to this common referral pattern may be costing their  practices tens or even hundreds of thousands of dollars of annual revenue.  For example, a primary care medical practice serving an average of 50 patients per day may be foregoing $60,000 or more of annual revenue associated with the referral of ultrasound outside of the practice.¹ Not only is valuable revenue walking out the door, you may be inconveniencing your patients and staff.          

In an environment where reimbursement and fee schedules are under pressure, shouldn't care providers consider whether onsite ultrasound service makes good business sense for the current and future health of their practices?

Case study: Three provider internal medicine practice
This three-provider internal medicine practice (serving approximately 80 patients daily), historically referred patients to the local hospital. Initially, the office manager and the physicians did not believe the practice had the ultrasound volume to support onsite service.  However, upon further review in which the appropriate use of ultrasound for its population of high risk and chronic disease patients was reviewed, the practice determined that it made good business sense to begin service one half-day per week. Within three months, the practice found it advantageous to the practice and patients to offer service three half-days per week, thereby capturing $150,000 in ultrasound referral revenue.

2. Patient care/compliance: Fostering an environment where a patient's needs are coordinated. Onsite ultrasound service promotes convenient patient care. Patients (especially the elderly) prefer having procedures performed in the comfort of their own primary care physicians' offices. If you had the choice between having a study completed at your primary care physician's office or some unfamiliar facility elsewhere, which would you choose?

In some instances, when a patient is referred to an alternative location for imaging, the patient does not follow through with the scheduled exam. Having the ultrasound exam performed in the physician's practice offers more accountability in the care process and more patient compliance with a physician's order. Physicians and medical staff will no longer waste valuable time determining whether or not an imaging study was completed and final results have been received.

For patients requiring more than one ultrasound imaging study (e.g. an echocardiogram and an abdominal exam), more than one appointment or travel to more than one department may be required when service is provided at a hospital or imaging center. This requires more time away from work or time out of an already busy day. Using the services of an ultrasound provider employing a multi-credentialed sonographer, these same studies may be completed in one service visit and at one location.  Patients appreciate this as it saves them time and money.

Case study: Multi-provider internal medicine practice
This multi-provider internal medicine practice had the service advantage of an imaging center located next door.  However, when a referral for diagnostic medical testing was made, the patient would not always follow through with the physician's orders.  When the study was conducted, medical staff would spend additional time tracking down results and final reports. If a patient was referred to the hospital, the practice would oftentimes lose track of the diagnostic care that was provided. After a careful review of the volume of ultrasound studies and these service issues, it made logical sense to provide onsite ultrasound service to eliminate these issues and capture revenue for the physician group.

3. Physician staff convenience: Remove the hassle in the scheduling and communication of imaging procedures. It is not uncommon for some medical groups to find it difficult to schedule imaging procedures. In today's busy environment, medical staff should not be burdened with scheduling hassles as they are already stretched in their patient care duties. When ultrasound imaging is provided on site, the schedule and availability of service are immediately known, so patient scheduling takes place in a simple and hassle-free way.

Offering ultrasound imaging services on site allows the practice and its physicians an additional way to build relationships with patients.  Many practices are striving to establish strong patient bonds and relationships. The time saved with onsite imaging and the opportunity to spend more time with the patient in the provision of a value-added service forges a stronger bond between the practice and patient.  

Case study: Two-provider primary care medical group
This primary care medical group enjoys the seamlessness and professionalism of onsite ultrasound imaging service. The practice has come to depend on the ease of diagnostic imaging, the reliability of service visits and the collegial relationship with the Sonographer who performs the technical service. The immediate feedback of preliminary ultrasound reports has been helpful to the practice and its patients when pathology or the lack of pathology necessitates a follow up imaging study or other procedure, saving the practice and the patient time and money.    

4. Physician control: Don't let your patients get lost in the referral maze. High quality medical practices strive to improve the health and lives of the patients that they serve with impactful care. Improving health outcomes is a primary focus. In order to have this beneficial impact, physicians must control how their patients are being treated and be accountable for the coordination and scheduling of diagnostic care. Onsite ultrasound imaging provides for this coordinated continuum of care.

More and more, practices are frustrated that higher paying services are often handled by other providers leaving primary care physicians to care for cold and cough cases. Onsite ultrasound allows for the primary care physician to provide a higher level of diagnostic care rather than referring this care outside the practice.  

Case study: Nine-provider internal medicine practice
This internal medicine medical practice wanted to ensure a higher level of care for its patients than what was currently being provided. In its experience, patients received diagnostic exams that in some cases were more than what was necessary, different than what was ordered or less than what was intended by the primary care physician. Additionally, the patient referral led to changes in patient care (e.g. the prescription of different medications) that disrupted the care being provided by the primary care physician who more fully understood the patient's condition. This internal medicine group was also frustrated with the loss of patients and value-added services to other providers. These providers were interested in capturing the revenue associated with higher reimbursing procedures and diagnostics; however, when lower reimbursing/lower value care services were required, patients were referred back to the internal medicine practice for care. Having diagnostic ultrasound service onsite allowed the practice to eliminate these issues, improving the level of care offered and adding profit to the group.

5. Patient cost: Be part of the solution to rising patient costs due to high deductibles and coinsurance. Today, patients are responsible for an increasing share of healthcare costs. The increased prevalence of high-deductible healthcare plans, health savings accounts and co-insurance responsibilities puts more financial strain on patients. In this environment, patients are more aware and sensitive to how their healthcare dollars are spent. Medical providers want to care for patients in the most cost-effective, efficient manner and are interested in new ways to deliver high quality care as efficiently as possible.

Practices are concerned about the cost of healthcare for their patients and want to deliver a high quality service without the higher cost associated with facility fees in the hospital or specialist care environments.  Ultrasound is an effective alternative to higher tech/higher cost imaging modalities such as CT, PET, MRI or nuclear cardiac imaging. These imaging modalities are tremendously valuable, but come with a cost that is three times the cost of ultrasound.² Some of these higher tech/higher cost imaging exams come with the risk of radiation. Onsite ultrasound is a cost effective way in which to "rule in / rule out" pathology — it is an effective diagnostic first line of defense.

Case study: One-provider primary care group
This primary care group cares for a small population of patients who have limited to no medical insurance due to recent job loss. Most recently, a self-pay patient was suspected of possible torsion. The practice group was able to work with this patient to provide the ultrasound exam, receive the necessary compensation for the study and save the patient over $600 of out-of-pocket expense in the process. The patient received the needed diagnostic care and saved valuable dollars.  The practice earned the loyalty of a patient for life.

Ultrasound service considerations: What to consider/look for in an onsite ultrasound imaging solution
How do healthcare providers evaluate the quality of an ultrasound provider?  What service level expectations should they have? Does onsite ultrasound make good business sense for their practices?  How much service do they need at their practices? 

First and foremost, clinicians must insure that service is provided by a high-quality ultrasound technologist who not only has the recommended credentials (see below) but also is experienced in the type of ultrasound that will be provided to patients in the practice.

 In addition to sonographer credentials and experience, providers must be comfortable with the ultrasound technologist to insure a healthy working relationship.  While not required, it is advisable to work with an ultrasound vendor which is accredited with the American College of Radiology, Intersocietal Commission for the Accreditation of Echocardiography Laboratories or both. These accreditations provide further assurances that the clinical ultrasound service will be provided in a high-quality manner accepted by the radiology and cardiology professions.

The ultrasound service vendor should be able to demonstrate the ability to offer clinical, operational, and billing support. On top of the required credentials and accreditations, the ultrasound vendor should offer clinical oversight and management to insure that clinical service is provided to the satisfaction of physicians.  In addition, an active quality assurance program needs to be in place to guarantee clinical service levels and adherence to accreditation standards.

Operationally, the practice should insist on consistent and reliable support in terms of scheduling, final reports, delivery of clinical reports and images for referral care, etc. Ultrasound service must go far beyond the simple technical provision of the clinical service itself. Providers want to insure that they are working with a professional provider who will support them and their patients.

In order for the service to make good business sense, the practice must be able to bill and collect for ultrasound services. Fortunately, the billing of ultrasound is not overly complicated and is generally similar to conventional practice billing; however, there are some basic billing procedures to be aware of from the start in order to realize the full economic potential of service.  Additionally, practice managers will want to make sure all ultrasound orders are valid and meet medical necessity using appropriate study indication codes (ICD-9/ICD-10) to insure timely reimbursement. 

The ultrasound service provider should be able to provide a fully compliant ultrasound services agreement that clearly outlines the duties of each party in the service arrangement.  Generally these agreements are for one year; however, the practice  should have proper protection to terminate the agreement with no more than 30 to 90 days' notice if service does not meet the expectations of the practice for whatever reason.

Does onsite ultrasound service make good business sense for my practice?  How much service do I need at my practice?
Generally speaking, if a practice refers out six to eight ultrasound exams (balanced mix of general, vascular and cardiac studies) per week, a half-day (four hours) of service per week will make good clinical and business sense. Any ultrasound service vendor should be able to provide enough flexibility to adjust the amount of service (increase or decrease) as practice needs change.

Randall W. Mountcastle, BA, MBA, is President of Insight Imaging, LLC. Insight Imaging is a leading provider of high quality diagnostic ultrasound services to physician practices in the southeast. The Company employs Sonographers who are multi-credentialed with the ARDMS^®. Insight Imaging is also accredited with the American College of Radiology (ACR) and theIntersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL). 

²Based on a sample of five imaging modalities/11 different study types and reimbursement as provided by the Centers for Medicare and Medicaid Services.

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