Navigating the complexities of healthcare insurance and diagnostic services can be challenging. When it comes to diagnostic radiology, understanding who processes claims and ensures coverage, particularly with providers like Fidelis Care, is crucial. This article aims to clarify the process of diagnostic radiology services, focusing on how insurance providers like Fidelis Care play a role, and what Medicare accreditation means for these services. While “Who Is Processing Fidelis Care For Diagnostic Radiology” might seem like a direct question about a specific department, the reality is more nuanced, involving a network of providers, insurers, and regulatory bodies.
Diagnostic Radiology and the Role of Insurance
Diagnostic radiology encompasses advanced imaging techniques like MRI, CT scans, and PET scans, essential for accurate medical diagnoses. For patients with Fidelis Care insurance, accessing these services involves understanding how Fidelis Care processes and covers these procedures. Typically, insurance processing for diagnostic radiology doesn’t mean Fidelis Care physically processes the images or conducts the tests. Instead, they are responsible for the financial aspect: ensuring services are covered, processing claims, and managing payments to healthcare providers within their network.
Medicare’s Accreditation Requirement for Advanced Diagnostic Imaging (ADI)
To ensure quality and safety in diagnostic radiology, Medicare has implemented stringent accreditation requirements for Advanced Diagnostic Imaging (ADI) suppliers. This requirement, stemming from the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), mandates that suppliers of the technical component of ADI services must be accredited to receive Medicare reimbursement. This has been in effect since January 1, 2012, and is a critical aspect of maintaining standards within the industry.
This accreditation is not for hospitals or critical access hospitals, but specifically for ADI suppliers, defined as physicians, practitioners, or facilities like Independent Diagnostic Testing Facilities (IDTFs) that furnish the technical component of ADI services. The “technical component” includes all the non-physician work, such as staff time, equipment use, and facility costs associated with the imaging procedure.
Advanced Diagnostic Imaging procedures, under Medicare’s definition, include:
- Diagnostic Magnetic Resonance Imaging (MRI)
- Computed Tomography (CT)
- Nuclear Medicine Imaging (including PET scans)
It’s important to note that standard X-rays, ultrasounds, fluoroscopy, and mammography are not classified as ADI under these regulations, although mammography is separately overseen by the FDA.
Designated Accrediting Organizations for ADI
Medicare, through CMS (Centers for Medicare & Medicaid Services), designates specific accrediting organizations to ensure ADI suppliers meet the required standards. These organizations are crucial in the landscape of diagnostic radiology as they are the bodies that assess and accredit facilities. While the application for CMS designation is voluntary for these organizations, those that are designated play a vital role in upholding quality within the industry.
Each designated ADI accrediting organization sets its own quality standards, which must, at a minimum, cover:
- Staff qualifications
- Equipment standards and safety
- Patient, family, and staff safety
- Medical records management
- Patient privacy
While specific standards may differ slightly between accrediting bodies, all must meet or exceed Medicare’s minimum requirements. These accrediting organizations are private entities and charge fees for their services.
Currently, CMS-designated ADI accrediting organizations include:
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American College of Radiology (ACR): A well-known and respected organization in radiology, ACR offers accreditation in various imaging modalities. They can be contacted at http://www.acr.org/Quality-Safety/Accreditation.
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Intersocietal Accreditation Commission (IAC): IAC accredits a range of modalities, including MRI, CT, and Nuclear Medicine. More information is available at http://www.intersocietal.org/.
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RadSite: RadSite is another recognized accrediting organization focused on promoting quality-based imaging practices. Their website is http://www.radsitequality.com/.
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The Joint Commission (TJC): While broadly known for hospital accreditation, TJC also has an Ambulatory Care Accreditation Program relevant to ADI suppliers. Details can be found at http://www.jointcommission.org/.
Change of Ownership and Accreditation
The regulations also address scenarios where an ADI facility changes ownership, ensuring continuous adherence to accreditation standards.
Transferring Medicare Enrollment: In cases of ownership changes where the legal business information (name, TIN, NPI, PTAN) remains the same, the existing Medicare enrollment can be transferred to the new owner. The new owner updates ownership details on the existing CMS-855B form.
Changes in Business Information: If the new owner changes the legal business information, a new CMS-855B enrollment application is required. Critically, in such cases, the previous NPI, TIN, and PTAN cannot be transferred.
Impact on Accreditation:
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No New Enrollment Application Required: If the Medicare enrollment is transferred without a new application, the existing accreditation can remain in effect, provided the accrediting organization grants written permission for the transfer within three months of the ownership change. A full accreditation survey must then be conducted within nine months to ensure ongoing compliance under the new ownership.
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New Enrollment Application Required: If a new CMS-855B application is necessary due to changes in business information, the new owner must seek new accreditation. The existing accreditation does not transfer to the new legal entity, and immediate application for new accreditation is crucial to avoid any lapse in Medicare reimbursement.
Both the previous and new owners are responsible for notifying the accrediting organization within 30 days of a change in ownership.
NEMA XR-29 Compliance and CT Services
Beyond general accreditation, there are specific equipment standards. The Protecting Access to Medicare Act (PAMA) introduced requirements related to CT equipment. Effective January 1, 2016, ADI suppliers and hospital outpatient radiology departments must use CT equipment that meets NEMA XR-29-2013 standards for dose optimization.
Failure to use NEMA XR-29 compliant CT systems for “applicable” CT procedures results in payment reductions from Medicare. This penalty started at 5% in 2016 and increased to 15% in 2017 and subsequent years. “Applicable” CT services are defined by specific HCPCS codes related to diagnostic radiological imaging for computed tomography.
To ensure compliance, providers must use the “CT” modifier on Medicare claims for CT services performed on non-compliant equipment. Accrediting organizations also verify NEMA XR-29 compliance during periodic accreditation surveys.
Fidelis Care and Insurance Processing in this Landscape
While this article outlines the regulatory and accreditation framework for diagnostic radiology, it’s important to circle back to the initial query about “who is processing fidelis care for diagnostic radiology.” Fidelis Care, as an insurance provider, doesn’t directly process the radiology itself. Instead, their role in the process is primarily financial and administrative:
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Network Coverage: Fidelis Care has a network of healthcare providers, including diagnostic radiology facilities. Patients typically need to utilize in-network providers to maximize coverage and minimize out-of-pocket costs.
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Pre-authorization and Referrals: Depending on the Fidelis Care plan and the specific diagnostic radiology service, pre-authorization or referrals from a primary care physician might be required. This ensures medical necessity and cost management.
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Claims Processing: When a Fidelis Care member receives diagnostic radiology services, the provider submits a claim to Fidelis Care. Fidelis Care then processes the claim, verifying coverage, applying co-pays, co-insurance, and deductibles according to the patient’s plan, and reimbursing the provider.
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Payment and Explanation of Benefits (EOB): Fidelis Care handles payments to the radiology provider and provides the patient with an Explanation of Benefits (EOB) detailing the services, costs, what was covered, and the patient’s financial responsibility.
In essence, “who is processing Fidelis Care for diagnostic radiology” is best understood as Fidelis Care’s claims processing department and their network of accredited radiology providers working in conjunction to ensure patients receive necessary diagnostic services with appropriate insurance coverage. The accreditation of ADI suppliers by organizations like ACR, IAC, RadSite, and TJC is a crucial underpinning, ensuring that facilities meet Medicare standards, which indirectly benefits all patients, including those with Fidelis Care, by promoting quality and safety in diagnostic radiology services.
For specific questions about Fidelis Care coverage for diagnostic radiology, patients should directly contact Fidelis Care customer service or consult their plan documents. For providers, understanding Medicare’s ADI accreditation requirements is essential for compliant billing and reimbursement, regardless of the patient’s specific insurance, as Medicare sets a benchmark for quality and standards in the industry.
