The American College of Radiology (ACR), in collaboration with the Radiology Business Management Association (RBMA), has raised concerns about a burdensome Medicare review process administered by Noridian Healthcare Solutions, a Medicare Administrative Contractor (MAC), responsible for Medicare Jurisdiction E and Jurisdiction F. These jurisdictions cover 13 states and several U.S. territories, primarily in the Western United States.

The issue centers on Noridian’s Targeted Probe and Educate (TPE) program, which places certain imaging services – such as CT abdomen/pelvis and lumbar spine MRI – under prepayment review. Under this process, Medicare reimbursement is withheld until the contractor reviews submitted documentation and makes a coverage determination. If documentation is insufficient or not provided in time, claims may be denied outright. 

ACR and RBMA argue that applying these prepayment reviews to professional-component-only radiology services creates significant operational challenges. In particular, radiologists in hospital settings lack access to the full clinical documentation required to justify imaging orders by patients' treating physicians, leading to elevated denial rates and significant administrative burdens.

In their letter, ACR and RBMA urged Noridian to exempt the hospital-based professional-component-only services from prepayment review, noting that the policy unfairly holds radiologists accountable for information controlled by ordering providers or facilities. And radiologists do not process referring physician orders or manage the performance of performing the ordered study. They are aware of the study only when images are sent to their workstations for interpretation. The letter observed the irony that the technical component of these services is not under review, but radiologists who did not take the order are being compelled to seek clinical information from the physicians who submitted orders for the imaging studies to the hospitals.

Despite these compelling arguments, Noridian has already issued a negative response to these concerns. As a result, both ACR and RBMA are evaluating potential next steps to advocate for policy changes.

Other MACs are also currently administering TPE reviews. Thus, the stakes of such prepayment reviews are significant. The providers who fail to demonstrate improvement after up to three rounds of review and education may be referred to the Centers for Medicare & Medicaid Services (CMS) for further action. Potential consequences include expanded prepayment review of all claims, extrapolated overpayment demands, referral to additional audit contractors, payment suspension, or even exclusion from the Medicare program in severe cases. 

Overall, the ACR-RBMA letter underscores the need for a more balanced approach rather than demanding clinical documents from physicians who do not possess or control them. A better approach would preserve program integrity while aligning with real-world clinical workflows – and would avoid unintended consequences for hospital-based radiologists and patient access.