The OIG just issued Advisory Opinion No. 10-04 which approved a program by a group of imaging centers to provide pre-authorization services for patients and referring physicians at no charge. This is a surprising turn from the path of prior Advisory Opinions on free services provided to physicians, where the OIG expressed major concerns about any service being funished by a provider that relieved a referring physician of a task the doctor would otherwise have done.
The rationale of the OIG in deciding to approve the arrangement had four components:
1. The service was available for all patients and referring physicians and was not tied to the volume or value of any physician's referrals, and since insurance plans do not have any uniformity in the requirements for who is to obtain the pre-authorization, it is only by chance if the physician is relieved of a duty.
2. No payments will be made to the physicians by the imaging centers, and there are no other rewards to physicians as incentives for referrals. The imaging centers only pass on to the payors the medical necessity information provided by the referring physician, and there is no assurance that the procedure will be authorized.
3. The process would be transparent, in that the persons seeking pre-authorization would identify themselves as representatives of the imaging centers, would make all their records concerning the requests to available to the physicians, and would have little ability to influence a referral because it would have already been made.
4. Economically, it is the imaging centers who are at risk if pre-authorization is not done properly, as it is their charges that will be denied. They therefore have a significant interest in making sure that the pre-authorization is received prior to their procedures being performed.
It is the 4th justification that seems to be the strongest here, since the risk is indeed all on the imaging center. It is just somewhat unusual to see the OIG directly recognize the economic reality of the situation in addressing a fraud and abuse concern.
While this Opinion, like all such Advisory Opinions, is limited to the specific case at hand, it provides guidance to other providers as to when it may be permissible to provide an "extra" to enhance your services. Whether it can translate into services beyond this type of administrative prerequisite for reimbursement is not clear.
