Radiology billing and out-of-network disputes

The professional component problem

Radiology billing splits into a technical component, billed by the facility, and a professional component, billed by the reading physician or group. The facility may be firmly in network while the radiology group is not. Patients have no say in who reads the study, and often do not know a separate physician bill exists until it arrives.

Under the No Surprises Act, radiology is an ancillary service. Balance billing is prohibited and cannot be waived by patient consent. The patient pays in-network cost sharing; the group's remaining remedy against the plan is open negotiation and, failing that, federal IDR.

What tends to be underpaid

• Emergency department reads at facilities where the group has no contract
• Advanced imaging interpretation — CT, MRI, nuclear medicine — priced against a QPA built from broad, low-complexity code medians
• Interventional radiology, where procedural work is compared to diagnostic benchmarks
• Teleradiology and after-hours coverage arrangements

Why QPAs run low in radiology

QPA methodology uses median contracted rates in a geographic region, and plans have wide latitude in how they construct those medians — including rates from contracts that bear little resemblance to the service actually delivered. Where a plan has few or no in-network radiology contracts for a code, it may fall back on eligible database rates. Groups rarely get visibility into which method produced the number, though plans must disclose QPA information on request.

Building a radiology IDR case

The strongest submissions pair the group's own contracted-rate history with that payer against the offer being made, and document complexity: study type, comparison priors, turnaround requirements, subspecialty certification, and the group's market position in the service area. Where a group holds in-network contracts with the same payer in adjacent markets, that comparison is direct and difficult to dismiss.

Eligibility screening first

Not every underpaid radiology claim is IDR-eligible. Claims covered by a state surprise-billing program go to the state process instead — 22 states have protections and 21 use some form of bifurcation, so a multi-state group can have identical claims routing three different ways. Screening every remit before filing is what keeps the fee spend productive.