Evolving dynamics in IR economics

Episode Transcript

Recorded live from the Cook booth at SIR and featuring leading experts in the field of interventional radiology discussing a wide range of IR-related topics, this is the Cook@ SIR Podcast Series.

Hi, everyone. Welcome to SIR 2025 Cook Podcast Studio. We have an interesting topic today. We’re going to talk about evolving dynamics in IR economics. So in this episode, we’re going to explore the evolving landscape of interventional radiology economics, highlighting the latest trends in revenue cycle management, reimbursement strategies, and policy impacts. We have amazing guest experts today, Dr. Matt Hawkins and Dr. Alex Fairchild. We’re going to provide some actionable insights to help IR professionals optimize their financial performance and also navigating the complexities of modern healthcare economics. Before we get started, I want to make sure we give a huge thank-you to Cook Medical for giving us this opportunity and talking about this very progressive and forward-thinking topic on economics, as it affects us daily. So again, Matt, would you mind introducing yourself, and then we’ll go to Alex.

Yeah, thank you, Ram, and also thank you to Cook for thinking about this. It is certainly progressive, and we appreciate that. I’m an interventional radiologist in Atlanta. My practice focuses on pediatrics, but from an SIR standpoint, I serve as the health policy and economics counselor, so I live in this reimbursement and econ space more than I maybe thought I ever would.

Thank you for everything you do, Matt. Alex?

I’m Alex Fairchild. I’m an interventional radiologist in Louisiana. As far as economics goes, I chair the Carrier Advocacy workgroup and I am soon going to be moving to CPT.

Awesome. Thank you for your great service to SIR, and especially in economics. So let’s start with Matt and then we’ll transfer to Alex. How would you describe the current state of IR economics today?

Kind of a broad question. I guess that’s what we’re here to talk about. Economics, if you look at how IR has evolved through time, I’d say the biggest pivot or change came when we separated as our own clinical specialty. Prior to that, there was a lot of overlap between the way we would do things, particularly on a revenue cycle management side with diagnostic radiology or other specialties. But with that pivot came much more clinically focused practices, which is going to involve evaluation and management services as well as interventional services—obviously procedures, periprocedural care, as well as multiple sites of service. And I know we’ll talk more about that later, but there are very few practices that can offer inpatient and outpatient clinical services and procedural services in three different sites of service, so the complexity really has shifted once we separated off as our own clinical specialty.

Matt, you deserve a lot of kudos for leading this charge through SIR, so thank you for those efforts, and we want to hear more about that, your activities as we delve in. Alex, give us your impression as a practicing in Louisiana and what’s your economic state of IR?

I mean, Louisiana is a unique place, obviously, and it comes with certain challenges and understanding the economic climate both nationally, but also locally, is super important in order to be able to continue to serve our population. And so we have a very underserved, very impoverished population, and so understanding how we can use economics in order to continue to care for our population is super important.

Yeah. I’m guessing you didn’t train in Louisiana—

Yeah.

… but do you find that when you started your practice there, you had to learn some local or regional aspects to the economics of your practice?

Absolutely. I was a little lucky in that I was born in Louisiana, so I was a little accustomed to its uniqueness, but I didn’t train there. And so certainly, there were unique aspects to being an interventional radiologist in the safety net hospital in Louisiana that I had to learn and embrace in order to be able to continue to take care of my patients.

Matt, I’m going to ask this next question. Given your longitudinal perspective and experience, what are some of the most significant changes you’ve seen in IR reimbursement models over the past five years? You kind of touched about them, but you’ve been instrumental in helping, along with SIR team members. What would you say have been the most significant?

Well, if you’ll give me a little poetic license, I’m going to go back more than five years, because when I started doing this, the biggest shift that we saw was the bundling of codes. And that goes back really from that time period of about 2010 to 2014. And not to nerd out here too much, but before that time, everything was what we call component coding, so if you catheterized a vessel, you coded for that. If you turned left, you catheterized; you know, you reported a code for it, you reported all the RS&I codes. And that bundling became a big thing for the RUC and CPT really around 2010. In fact, the data point we use is from 2010 to 2012, we were so busy bundling all of our codes that we actually came out with no new codes for new procedures that IRs were doing. And that was the beginning of rapid decrease in reimbursement. So we took procedures, and they were dropping in values of 33%, 50%. And so that was the first time where all of a sudden we had to tighten things up, because before that, to be quite honest, we were pretty fat on the hog. You could be pretty sloppy with your revenue cycle and there was enough money that people still did okay. So that was the first big moment where I think IRs realized, “Oh man, we better pay attention to this or we’re not going to be able to run a fiscally solvent practice.” Like Alex said, you have to run a good business so you can take care of all the people that need to be taken care of.

Yeah.

So that was the first big one. Since that time, really the inclusion of all of the imaging codes into the procedural code, that’s been the biggest thing or been one big thing. And then the other is trying to figure out, how can we actually budget for the expensive devices that we use in multiple sites of service and not have that impact the professional RVUs that we do for those same procedures, because it is a zero-sum game and if we have really expensive stuff in one place, it has to be paid for from somewhere else, do I’d say that’s one of the biggest challenges we’re facing right now.

Okay, thanks. Alex, anything to add on that one?

I think that pretty much covered it all. One thing that I think that we really do need to pay attention to is how we get paid in different places and how that’s changing, and making sure that we’re making the adjustments that need to be made as that changes.

I know that economics has a lot of alphabet soup. Is there about three or four terms, Matt or Alex, that you want to just kind of define for our audience? So, you mentioned CPT, RUC. There’s a ton, but maybe the top three or four.

I think that one thing that’s really important to know when you’re talking about economics is understanding Medicare and the alphabet soup that goes along with Medicare. Obviously, all of our payments are really tied to how Medicare pays for things. And so there are a couple of alphabet soup terms that I think are really important to know—things like MACs and LCDs and NCDs and CAC network. So, essentially, whether or not you get paid for something by Medicare is going to be in part determined by an LCD, which is a local determination of coverage. And so in that particular area for a MAC, which is a private company that is servicing the Medicare for that area, “Will vertebroplasty be covered for these indications?” And as a physician, we are, you and I are both part of the CAC network, where we can go and be an expert and say, “These are the reasons why we should be able to cover it.” And there are certain time periods when that might come up and we have the opportunity to speak up and be those local experts to really affect how a local determination is made. So we have the CAC network, group of physicians who are very involved wanting to get the coverage for that particular MAC and then to determine that LCD. In a global way, there’s an NCD, which would be the national coverage. And so, understanding that there are these different coverage and how Medicare works and services, I think is super important.

Thanks, Alex. I think that kind of also points to why we might have colleagues who are in the Southwest or Northwest or Northeast or Midwest who have different experiences getting certain things approved or reimbursed.

Absolutely.

So there’s variations within our continental US as well. I’m going to switch a little bit to the revenue cycle management side. Let’s kind of—based on a constituents and our feedback, walk us through maybe where the most IR practices are losing revenue in the billing process. If you had to say, “You know what, take a look at this and see if you guys are doing this part right.” Alex, do you want to take this first?

Sure. I mean, I think that one area that we lose revenue is E&M. We do the work, but we don’t bill for the work. We’re really bad about it. And so, in full disclosure, my husband’s an OB-GYN and he laughs at how little I knew about E&M when I graduated fellowship, and I’ve done a lot of work to understand it and now teach it to my trainees to make sure that they come out of training understanding how E&M works, how you bill for E&M, how you write your notes so that you get paid for the E&M and the work that you’re already doing.

Yeah, I mean, I’m glad Alex brought it up and I know we’re going to talk more about E&M, but again, that’s—go back to alphabet soup, that’s evaluation and management services, writing notes for clinical work that you do. Practices hemorrhage money for not documenting for that. And the target I always give practices, you really should aim for, if you’re a true clinical IR service, right now set a goal for between 15 to 20% of your revenue to come from E&M. And that puts us in line with similar-type specialties such as vascular surgery and others. So that’s a place to shoot for. But I mean, other than E&M, where we do work and don’t bill anything for it, so we have a 0% success rate, documentation of the procedures that you do. If you do not use templated notes to capture all the parts of the procedure that you perform, I will almost guarantee you with 100% that you are underbilling and undercollecting for the procedures that you’re doing, as well.

Yeah, absolutely. I think the E&M speaks a lot to what we have that ability to quickly redeem and capture, for sure.

And with the notes, I just want to make one other point is, in the notes, giving the clinical scenario as to why you are doing something when you’re writing your note for your procedure is super important too, and I think people underutilize that area of their procedure note and leads to denials.

Kind of talking about that, how about a follow-up side of things? Let’s say you do a procedure and, you know, see them in clinic or there’s an opportunity to follow up your own care. It’s the right thing to do for patients, but there’s also revenue on that aspect too.

Yeah, you get into the aspect of, what can you bill for following a procedure that you do? And so it’s probably a good time to introduce this concept of zero-day global versus 90-day global payments. Ninety-day global is where most surgeons live, which means they do a surgery, whatever services they provide in the next 90 days, they get paid for upfront. They don’t get any more than that. If they do less work than what is built into that code, then they make more money than they maybe should. If they do more work than what’s built into the code, they lose money. And with us being in a zero-day global period for almost all IR procedures—not all, almost all—it allows us, then, that when we provide subsequent care for that patient, whether it’s inpatient rounding on an abscess drain or a chest tube or following them up in the clinic after a UFE or a similar or TIPS or a similar-type procedure, it allows us to bill separately for those services, which really does present us an opportunity, but you’ve got to document the work.

Yeah, no, great tip, Matt. I think doing that follow-up care, it’s good patient care and many of us are probably doing it, make sure we are accounting for that. Kind of touching that, how can practices or IR docs, what should be the culture of maybe engaging more effectively with their coders or any of their revenue cycle teams to ensure proper documentation coding is happening? Maybe you can give suggestions like who you should go to, how often, and yeah, I’d to hear your thoughts. Alex, you want to start?

Sure. It really, I think depends a lot on the coding team that you have. I have been part of practices where we had really robust coders who were very active, around all the time, would come to you in person and be like, “Hey, you know, you didn’t put this in your report. You probably should have done that. Would you like to—”

Issue an addendum.

… Yeah, “Would you like to look at that again?” And I learned a lot from them because of that. And having that constant feedback and interaction I think was so important to my learning about coding and what I can do better on my side in order to make sure that we’re capturing the work that I’m already doing. But there are practices where that’s not happening and that may be set up by the hospital and you have off-site coders that are not as engaged. However, you can reach out to them, and finding out who that person is that is doing the coding and starting a dialogue with them I think will be good for you as the physician to learn about what you need and what you’re missing and what you’re consistently missing, so you don’t miss it anymore. And also, they’ll learn from you, and it is that constant interaction that is going to benefit the entire system.

Yeah, so introduce yourself, right?

Yeah.

Yeah, exactly. Get to know your coder. I mean, practical advice, things I’ve done right and done wrong. Engage with your coder from day one. Every time we hire a new coder to our coding team, they actually come to the suite and observe cases.

Oh, great.

When I started early, we met quarterly with our coding team just to see what we could do better and also let them ask questions. If you start doing a new procedure at your practice, let your coders know that it’s coming. And then if you do—or when you should—bring in a company to do an external audit of your coding, always approach it from an educational standpoint. Like, “Hey, y’all, we’re just trying to get better at this because we want to make sure we’re capturing the revenue.” They’ll appreciate that, but you’ve got to have that relationship before trouble comes.

Absolutely. I never realized this, but when I was in training, I, along with attending—as a fellow—I, along with the attending were also CC’d on the email that said, “Hey, you forgot to include ultrasound access or this,” so it just raised my radar about it by the time I became an attending. So it was huge value. I didn’t see it until later. But, yeah. Okay, so, a lot of AI stuff is going on, and with billing and all this, what role does automation or AI play in some of this revenue cycle efficiency? Are we seeing some of this come and being developed in IR space? Matt, you want to start here?

Yeah, I mean, again, where is it happening now? I’ll go back to E&M. You’re seeing a lot of AI work, listening between a patient and a physician interaction and dropping your note within some type of a structured template. That’s happening now. It doesn’t involve performing procedures—and I don’t want to go too far down this road, because I want to hear what Alex says—figuring out how we get reimbursed for AI in the suite is going to be a real challenge for us, looking long term or that 5-, 10-year timeframe, because we always have to figure out “What is physician work?” and “What is helping us do physician work?” and “How do you get paid?” But right now, today? You know, AI can help you be much more efficient in the clinic.

Absolutely.

Yeah, I echo that. I think the challenge will obviously be with AI is, you still have to review it. And I don’t want people to get trapped in “AI is this perfect thing that doesn’t require any physician work,” because it does. There is physician work in checking the accuracy of that AI. And so to Matt’s point, how do we bill for it, and where’s that coming from?

I’m going to switch a little bit towards reimbursement strategies now. I think, Matt, you helped lead the revenue cycle course back in January. Went very well. I was able to attend and participate in that. There were some things you said there—so this is the leading question from there: Are there specific CPT codes or procedures or things in IR that are most often underutilized or misbilled? I remember arriving to my own practice and we noticed there was something that we do all day that we weren’t putting in into our reports, such as ultrasound, but yeah. But I know that’s probably—you want to share about that and how much it actually can help?

Yeah, the two obvious ones are ultrasound needle access into a vein—and there’s some specific things you have to put in that report to bill for it. We do it all day every day. It is not a huge number of RVUs, but if you recapture it, it makes a real impact. And the other easy one is catheter subselection codes. So when people actually catheterize a vessel and do angiography, you bill for the catheterization. and if appropriate, you also bill for the angiogram. And if you’re not descriptive of what vessels you’re catheterizing, your coders then cannot report that code. But those are the two. by far and away, that I see when we look at practices and their coding practices.

Great.

And I think that—just a tip—when setting up your templates, figuring out a way to really pull that information out for your coders to be able to easily access what you’re catheterizing and what you’re doing an angiogram on.

Yeah. Do you guys sometimes add the second order, third order, just to help—

Always.

… clarify right next to it in parentheses? So those are—do as much as you can to help, right?

Yes, exactly.

Okay. Well, let’s talk about this outpatient, inpatient—how do outpatient versus inpatient settings affect IR reimbursement, and how should practices adapt? Are there strategies you should think about when you see these differences?

So, site of service, it’s one of the, I think, most critical parts of understanding revenue cycle. It’s like the next level above how to report a code and how to get paid for it. But people have to understand that, depending on where you do the procedure, you’re going to get paid by a different fee schedule that comes from CMS. So you asked about inpatients. Well, CMS produces an inpatient rule every year that has reimbursement from a diagnosis-related group, or a DRG. When you do a procedure as an outpatient, the fee service or outpatient services is—comes from the HOPPS, or the Hospital Outpatient Prospective Payment System. Those get paid by something they call ambulatory payment classifications, or APCs, back to your alphabet soup. And then if you do something in the office, your technical reimbursement actually comes from the Medicare physician fee schedule. They do not all pay the same. And so what is important to know is, how much you get paid and the mechanism by which you get paid truly depends on what setting you are doing the procedure in.

Yeah.

A really important kind of concept is that if you are doing a procedure on an inpatient, you’re not getting paid for that individual procedure that you’re doing for that patient, which is very different than on the outpatient setting, where you are getting paid for that individual procedure. So on the inpatient side, it is this bundled payment or the single payment for the disease process for which the patient came in. And if you’re doing procedure after procedure after procedure, you may end up—not you personally, but the hospital—may end up losing money if you’re doing all of these procedures as an inpatient.

Great point, Alex. So I think one of the things that I think a lot of us do is, we assess the patient—there’s an E&M evaluation that happens—and if it’s a procedure that may not be indicated in the patient, inpatient or acute, you could actually coordinate the care as an outpatient, right?

Absolutely.

First, most important, doing the right thing for the patient, and then kind of thinking about these aspects as well.

A common one that we get a lot is, a patient will get a CT scan in the ED, be getting admitted for some —say, pneumonia—but there is a liver mass or a kidney mass that needs to be biopsied and we get consulted to do that. Well, that’s not their primary problem coming in to the hospital and it’s probably better served as an outpatient biopsy.

Absolutely, yeah. Establishing oncologic appointment, and all of those things.

Absolutely.

Great point. I think that happens to many of us and something to be mindful of. What are some of the trends that—you mentioned bundled payments, Matt, that happened about 10-plus years ago. What are some of the trends you’re seeing around bundled payments, and how do they affect our IR services, especially going forward?

Yeah, we haven’t seen much bundling, fortunately, over the last four or five years. It’s been nice to kind of get a break and get a relief from the bundle payments. But what we’re seeing now, historically, if CMS or others wanted to pay less for a service, they would just decrease the number of RVUs that they were paying out. Now we’re actually seeing professional RVUs hold steady, and the real challenge now is big cuts to the technical component of payments, especially in the office-based setting. So we were at a place where payments in the office and payments in the hospital outpatient setting were pretty similar, again, 5, 10 years ago, but now we’ve seen a direct attack, if you will, on technical reimbursement in the office for some of the higher-paying office-type procedures. So practices are then responding by potentially shifting their site of service from an office into an ASC. And in the ASC setting, you get paid from a different fee schedule. So back to that site of service and the impact on reimbursement, that’s probably the biggest trend I’m seeing today in 2025.

Got it, thanks. Let’s kind of switch to policy, regulatory things. I know you guys are both really well-versed in this. Well, recent CMS changes or maybe anticipated changes, how should IRs position themselves to remain financially viable? What could they do on the education side? I mean, what could they do on the practice side? Any one of those realms. Alex?

I think that when you’re looking at policy, there’s obviously a couple of things that affect all physicians, not just interventional radiologists, decreasing reimbursements, especially compared to inflation. And so there are these global issues that I think affect us all as physicians. I’m going to put a plug in here for SIRPAC and what they are doing in order to help mitigate some of these changes, going to the policymakers and really advocating for interventional radiologists and these things that are affecting us on the legislative stage. So, I think it’s important that we do understand that there is SIRPAC, that they are active—

Tell us a little bit more about SIRPAC. I know you guys are very familiar with it. Yeah, go ahead.

So essentially, it is that kind of advocacy within SIR that is going to our legislators to advocate on our behalf, to have our reimbursement tied to inflation and to help mitigate some of those cuts that are happening, speaking to the legislators, trying to make these changes, and benefit our specialty as a whole from that avenue. And I think it’s a very important avenue. Obviously, we’re busy. We don’t have time to be going and speaking to our representatives on a regular basis, but that’s how we make change. And so by supporting SIRPAC, we’re able to make that change with little effort on our end.

And the thing about political action committees—again, SIRPAC is the only political action committee dedicated to interventional radiology—you never know when issues are going to come up on the Hill. There are things that are thrown in last minute into bills or packages, so you have to have those relationships on the Hill to mitigate those changes. And if you don’t have those relationships, you never know what’s going to happen. As far as in the current realm, how can practices still succeed and run a fiscally solvent business? I usually recommend diversification, just like anybody with your personal portfolio. I would love it if every practice had an inpatient presence, had a hospital outpatient presence, and had an office-based presence. And that way, by continuing to have multiple sites of service, our value proposition as IRs, we have a broad array of procedures and organ systems that we work in, which again protects us as compared to some of our other surgical specialties that really rely on maybe perhaps just two or three core procedures, so that diversification, if you can do it well, will protect you.

Yeah, I have a feeling it also probably increases your latitude of the access to type of patients, whether it’s Medicaid patients, insurance, or that kind of outreach can also happen indirectly by offering different sites of service.

Absolutely. I mean, in addition to having a diverse profile of locations that you can work, but also a diverse payer model as well, so not just taking Medicare, but also having private insurers, not just taking private insurers, but you also want to have your Medicare.

Yeah. And diversification of practice, it goes to who you’re contracted with to pay. There are a lot of practices that expose themselves to a lot of risk because they may only have one big contract with one or two payers.

Exactly.

And again, it’s no different than investing in the stock market. You put all your money in one company, you never know how that’s going to go.

Any surprise regulations impacting IR? You kind of touched upon it, Matt, there are some things that are being adjusted, but especially between a hospital and office space. Do you want to maybe mention one or two things that are being affected related to regulations?

Yeah. Biggest regulation, again, I’ll hit on it again, is the technical reimbursement in the office space setting. And so what does that kind of look like moving forward? You’ve heard for years people talk about what they call site-neutral payments, so regardless of the location, are we going to pay people the same? I don’t know. There’s also a discussion of, do we create a different fee schedule, perhaps, to pay for the really expensive items in the office that the existing technical reimbursement upfront doesn’t even pay for the device itself, let alone your clinical staff and your suite time and your electric bill and all your rent—

Overhead.

… all the other things that you have to pay. So I think that you’re going to continue to see that space evolve the most, and how does that end up impacting ASCs in the hospital outpatient setting? That’s something we’re paying very close attention to as an economics team.

Perfect. What do you think is the anticipated timeline? I know you can’t predict. What are these kind of things? What’s the timeline evolution of how these things kind of come about? Is it about a year or six months? Is it multiple years?

Yeah. CMS will nickel-and-dime you all the time. It is not like it’s coming in six months or it’s coming in 12 months. It’s body blows. It’s body blows every year, and you’re in for every round. You’re every round of this fight.

Yeah, okay. So let’s kind of talk about some operational things related to economics. So let’s say you’re a leader, you’re chief, you’re maybe the CEO of your group. What can IR leaders or practice groups, what are some of the practical strategies to improve financial performance without compromising care? I know we’ve talked about maybe things related to E&M, but like maybe from an operational business standpoint, whether you’re an academic center, to look at, is it supply chain or other things, or if you’ve got your own OBL, what are some of the practical things?

Actually, one thing that I think that is underrecognized is looking to denials. I think that a lot of denials go unchallenged, and when that happens, we’re losing the opportunity to take care of our patients, and we’re also losing revenue. And so it’s a lose-lose proposition when we don’t challenge denials. And there is a concerted effort on the insurance side to just send a denial and see how—if it sticks. And one thing that I’ve learned over time is that you get better at challenging denials the more that you do it. At first, everybody’s terrible at it, but you get better because you—

There’s help. Yeah, we’ll talk about it.

There is help. But you get better the more you do it, and the more that you talk, you do these peer-to-peers, you learn the language, you’ve learned the things that they’re looking for, the better you’re going to be. And then you can start helping other people. And that’s, I think, what you’re alluding to.

Yeah. You want to tell us about that too, Alex?

So the Carrier Advocacy workgroup within the Economics Committee is a very active workgroup, and we have a couple of strategies that we work on in order to help membership with denials. First one, longest standing one, is writing letters for specific procedures—so things like Y90s, or ablations, or UFEs, all of those things that get denied, we have letters for, and they address the specific issues that payers have for giving those denials. They’re very well researched, they’re very well cited, very well written. It’s a group of very active individuals within SIR that write these letters and do a phenomenal job, and they’re updated, so as new research comes out, we update the letters in order to make sure that they’re as relevant as possible.

Alex, special shout-out to you for leading that Carrier Advocacy group, so thank you so much.

And thank you for taking over. I’m excited to see where it goes.

Yeah, I love that you started with denials, because I do think working backwards from an operational standpoint is the way to do that. Everybody should know their denial rate. You should look at the denials and figure out why they get denied. The letters that you guys just talked about are free to all members. They’re going to help you, especially with the higher paying procedures that some insurers are just going to deny the first time regardless of what you put in there. But you also learn why other things are getting denied. When I looked at this in our practice early on, the most common reason we were getting denials is because we were submitting the wrong code for reimbursement. That is a very fixable—

Simple.

… very fixable problem. And then you work your way backwards. So if you go back to the actual procedure and documenting the work that you do? Operationally, use structured templates. And if you want to build structured templates, I tell people, start with the five most common procedures that you perform and the five highest grossing per procedures that you perform. If you get those 10 structured templates, you’re going to be 90% of the way there. And then you go back to prior authorization. As a leader, you should work with your coders or whoever’s doing your prior authorization to make sure they have a list of the procedures that you do and the appropriate codes are getting submitted for prior authorization. Again, this is more in the outpatient setting, but it starts with denials and you work your way backwards.

Yeah, great tip. I think it’s—rather than prospectively thinking, “Oh, this is what I’m going to do”—I think you immediately yield quick wins. Yeah, thank you for that. Great tip. How should practices think about case-mix optimization, especially in the context of value-based care? Diversifying, I guess, your portfolio of cases as well—is that something that especially new attendings or changing practices or graduates or other just actually practice leaders? Matt or Alex?

I mean, I think that the recommendation I always give to every one of my trainees is, don’t pigeonhole yourself into a specific one type of procedure. Learn how to do everything. You never know what’s coming on the horizon, and the more skills that you have, the more able you are to pivot to those new procedures and be comfortable with new things as they come up. Typically, it is those new procedures, when we get evaluations for them through the rep, that are higher paying, higher reimbursed, so you want to be able to do them, and if you focus too narrowly when you come out of training, you’re going to be in a less able spot to be able to adopt those new procedures.

Yeah, and as a leader, you want to be hiring staff who can bring something new to the practice.

Yeah.

And again, shout-out to our CPT team, but we now have new codes for thyroid ablation.

Absolutely.

We’ve added a number of codes, especially in the MSK and pain space, where that’s new revenue opportunity that didn’t exist. But if nobody in your practice does that, you’re obviously not able to tap into that potential opportunity.

Absolutely. That’s a great example of especially what the economics team and SIR team have worked on. What are some of the metrics that IR departments should be tracking to assess financial health and efficiency? Is it, like, gross revenue? Is it margins? I mean, those are big economics terms, but what are some of the things that just every day for leaders, or even actually somebody starting their own practice?

Yeah, I’ll jump on this one for sure. What I will tell you it is not, is professional RVUs. If you are in a practice that is only measured by your professional RVUs, and especially if you’re in a mixed IR-DR practice, you’ll never be successful. Professional RVUs are helpful over time to see trends, but they are not helpful at a moment in time to evaluate economic success. So with that being said, what do you want to track? You’ve got to understand what your technical revenue is you’re generating, and if you are in a hospital-based practice and you are employed by a hospital, you really need to understand what your technical revenue is that you are producing for that hospital.

Yeah, Matt, I’m going to emphasize that because we see this—you know, I’m in part of IR forums and whether my trainees, they’re like, “Oh, I’m in this practice. They’re just saying I’m not making my cut here.” And I think you bring an important point. You got to have complete data to analyze your contributions and your value.

Yeah, your average interventional radiologist in the private practice space is about 8,000 RVUs a year. And that’s just give or take. Your average diagnostic radiologist, who we know has a different workflow and some different components to their job, is going to earn about 12 to 13,000 RVUs in a year just by doing the work that’s in front of you. And that’s a baseline. And so you will never be able to keep up, from a professional work RVU standpoint, as an interventional radiologist. And that’s okay, because we generate revenue in a lot of other places that you’ve got to understand.

Yeah. What are some of the other variables—especially some folks who are thinking about different practices—so that they can have the talk with their CEO or their practice president. Can you share the technical—what are the other things, “Hey, here’s how much imaging that we’ve ordered and created business. Here’s the referral patterns that we’ve created, or intake of referrals to our practice”? A couple other variables, Alex, that you would—

I mean, I think that that’s what we constantly try to show is that, by having a really active outpatient clinic, it does provide for the additional imaging that is being collected and the referrals to other providers, kind of looking at our patients in a holistic way as opposed to “We do a procedure and we’re done.” We really are adding value to the entire system.

Yeah. And to look at other ways to get paid, there are a lot of ways to do it. I would tell groups, if you’re thinking about it, hire a professional, and you want to land in a place that your practice is comfortable with and your hospital’s compliance department is with. You can get paid a dollar amount per RVU that you generate. You can negotiate that. You can negotiate stipends for trauma call or whatever the other call is, and the hospital pays a stipend for an FTE. You can do some sharing of technical revenue, although in some states, there’s stark limitations to what you can do there. So there’s a lot of ways to do it. Hire a professional, do it right, and make sure it’s a situation where the hospital and your group is comfortable.

I think that that is great advice about hiring a professional. Too often, we are busy doing clinical work, and understanding all the nuances of what that takes really does take a professional who can look at it from all aspects.

Yeah. The last thing you want to do is come up with an arrangement for payment that then turns out doesn’t clear all the legal boundaries.

Sure. Yeah. Yep, great.

Get help upfront.

Okay. So let’s look ahead as we’re going to get to a close to our session. Looking ahead, where do you see the greatest financial risks, but at the same time, opportunities for IR?

Yeah, I mean, the greatest financial risks come from continued reimbursement cuts, particularly from CMS. What we have seen is a little bit of erosion of the traditional CPT and RUC process. So CPT and RUC, we’ve talked about it a lot today, but a lot of people don’t realize, it’s owned by the AMA. It is not a government agency, but it allowed physicians to take ownership of how we get reimbursed for the services that we provide. And then CMS would take that recommendation almost 95% of the time. Well, that got criticized. And so now, despite this very rigorous CPT and RUC process, we’re seeing more arbitrary reductions in reimbursement just because CMS doesn’t want to pay for a particular procedure in a particular location. That is the continued threat, because you just don’t know what procedures they’re going to go after. Typically, they go after the highest paying procedure, but if we’re also providing high value with those procedures, there’s the threat that you’re going to affect access of care at some point to the most cutting-edge technology that we have available just because it’s “expensive.”

Alex, what do you see the opportunity?

I think that what is so unique and why we love interventional radiology so much is how we’re able to—bless you—how we’re able to reinvent ourselves time and time again. We pivot into new areas of medicine constantly, and I think that it is that nimbleness of the specialty that allows us to continue to grow and to thrive.

Yeah, awesome. Thank you. Well, I think this is a good transition for our last question. What’s one piece of advice you’d give to an IR fellow or early career, or maybe even established, about the business side of medicine? Alex, do you want to start?

Yeah. I think that embracing the business side of medicine as a trainee and really trying to learn from the people around you as a trainee and making it part of your language from the very beginning—just like medicine is a language that you have to learn, economics is a language that you have to learn—and the earlier you try to engage it and adopt it, the better off you’re going to be in the long run.

Yeah. From a practical—if we want really practical—I would tell every trainee that’s out there to make sure they get the SIR annual coding update. That is free to all members, and just reading through that, that’s where most of us started—and not with the goal to become a super expert in this space, but you need to be smart enough to make sure you can ask the right questions and find the right people to help you. What’s nice about the SIR right now is, they have seen that this is really important, so for others, if they are looking for practical ways to learn about work in this space, we now will have the Business of IR stand-alone meeting that SIR is going to offer on an annual basis. So no longer is it just the annual meeting, where we focus on clinical work; the SIR has seen that there is a need for education in this space and dedicating a stand-alone meeting on an annual basis now. If you read the SIR coding update and you attend the Business of IR meeting, you’re going to be ahead of 90% of your peers.

Yeah. No, great tips. Well, you know, this has been a wonderful session. I forgot I didn’t introduce myself, but I want to thank Dr. Alex Fairchild, Dr. Matt Hawkins for being here, and Cook for sponsoring this session. To conclude, this is Ram Chadalavada. I’m at University of Cincinnati and a interventional radiologist and also been part of the Economics Committee through SIR. Thank you. I’ve had the privilege of working with both of you, and this has been a wonderful session. Thank you for being here.

Ram, thank you so much.