Concerns Over Medicare Claims Review Practices by Noridian

The American College of Radiology (ACR), in collaboration with the Radiology Business Management Association (RBMA), is raising alarms over the Medicare review practices implemented by Noridian Healthcare Solutions. Noridian serves as the Medicare Administrative Contractor for Jurisdictions E and F, covering 13 states and various U.S. territories, predominantly in the Western region.

The crux of the issue is Noridian’s Targeted Probe and Educate (TPE) initiative, which scrutinizes prepayment claims for certain imaging services, including CT scans of the abdomen/pelvis and lumbar spine MRIs. This process delays Medicare payments until adequate documentation is reviewed and coverage is confirmed. Dismissals or untimely submissions can result in denied claims, impacting healthcare providers significantly.

ACR and RBMA critique that these rigorous reviews, focused solely on the professional component of radiology services, induce operational hurdles. Hospital-based radiologists often lack access to the detailed clinical documentation necessary for validating imaging orders, leading to elevated claim denial rates and intensified administrative burdens.

In response, the ACR and RBMA have requested Noridian to exempt hospital-based professional component services from prepayment reviews. They argue it is unfair to hold radiologists responsible for documentation managed by the ordering providers and facilities. Radiologists typically review imaging studies only after they are sent for interpretation, without being involved in the ordering process, pointing to an inconsistency in reviewing practices.

Noridian, however, has dismissed these appeals, prompting ACR and RBMA to explore further advocacy and policy adjustments. This issue underscores a broader challenge, as other Medicare Administrative Contractors also employ TPE reviews. Providers failing to improve during review cycles risk consequences like expanded prepayment scrutiny, overpayment recovery, audits, payment suspension, or potentially Medicare exclusion.

The ACR and RBMA's joint letter underscores the necessity of policies that uphold program integrity while accepting the practicalities of clinical operations. A balanced approach could alleviate the negative impacts on hospital-based radiologists and safeguard patient access to vital imaging services.