OIG Advisory Opinion 12-10 – Radiology Insurance Pre Approval Service

A recent OIG advisory opinion addressed the legality, under the Medicare Anti-Kickback Statute, of a radiology group’s proposed program to provide free insurance pre-approval services when the treating physician orders a radiology service. The radiology group requested the advisory opinion out of concern that the potential value to the treating physician through reduction in administrative burden involved in gaining pre-approval could be considered to be “remuneration” that is intended to induce referrals to the radiology group.

In response to the advisory opinion request, the OIG stated that it believed the risk of fraud in the pre-authorization program to be minimal. The OIG reasoned that in the majority of cases, the treating physician is not likely to know who is responsible for obtaining pre-approval because the responsibility for obtaining pre-approval varies by insurance companies. The OIG also found it relevant that the program was made available to all patients without consideration for the source of referral or the identity of the payor. The OIG pointed to additional safeguards that were built into the proposed program.

Diagnostic or ancillary service providers who offer or wish to offer free pre-authorization services should reference the OIG Advisory Opinion No. 12-10. Although a favorable decision was reached in that opinion, the decision only protects the party who requested the opinion. Free pre-authorization services by diagnostic and ancillary providers can raise Anti-Kickback Statute concerns if a program is not structured to reduce risk.

For more information regarding this or other health law issues, contact John H. Fisher, II at Ruder Ware.