People often ask me what I think will/does happen when private equity groups fail. The answer I’ve always said is it probably depends.

The work needs to get done, so there are three big options:

1. Direct hospital/system employment probably with locums in the short term
2. New private practice
3. Outsourced to teleradiology firm (potentially with IR/DR split and locus/direct employment for on-site procedural work)

There was a story this past summer in Radiology Business that I don’t think I shared here: to my knowledge, Mid Atlantic Radiology Consultants is the first completely new group to form to take back work from a reportedly unsatisfying Radiology Partner’s owned practice:

[President and CEO of Trinity Health Mid-Atlantic] “Woodward declined to identify the “large scale” imaging group to the publication, citing contract confidentiality requirements. But he shared a personal belief that such PE-backed provider groups “serve their shareholders’ interest, not the patients’ and doctors’ and hospitals’ interests.

Radiologists he spoke with conveyed a dissatisfaction with investor-backed groups that “come in and forget about the patients.”

This is an example of a hospital that chose to help create an independent group instead of trying to bring everyone in-house. Now, it’s worth noting this is probably not charity. They may have realized they’d have a harder time recruiting in the market with direct employment. They may not have had enough outpatient work to fully justify the numbers of rads they’d need to cover the on-site call pool. They may have preferred an external entity that they could blame when things go wrong or pressure, which wouldn’t be possible the same way for employed rads. The accountability calculus is simply different.

Regardless of the reason, it happened. I know some other hospitals, like some in Chicago, have shifted rads in-house. Still others, like one in Tulsa, have resorted to teleradiology.

Here are several things to consider about learning radiology in addition to my articles on Approaching the R1 Year, How to be a First Year Radiology Resident, and Radiology Call Tips.

Develop Robust Search Patterns

Real search patterns are not just the order in which you analyze a fresh scan, they are a series of if-then statements:

If I see this finding, then I will look carefully at this other structure for an associated abnormality.

For example, if I see a lobar hemorrhage, I will look extra carefully at the dural venous sinuses and regional cortical veins on this non-contrast CT to ensure there is no hyperdensity to suggest thrombosis. If I see a spine fracture, I will look extra carefully at the soft tissues to ensure no obvious epidural hemorrhage or interspinous widening to suggest and ligamentous injury. If I see scalp swelling, I will look at the immediate underlying bone and underlying & countercoup intracranial contents to ensure no subtle fracture or hemorrhage escaped my notice on the first pass.

Interrogate Your Knowledge & Test Yourself

In today’s educational environment, asking pointed questions–especially those designed to stretch and assess your knowledge (pimping)–has fallen out a favor. This may be a combination of generational changes as well as the desire to create a safe space for learning, but regardless it is not as common as it used to be.

That being said, it is important for you to interrogate and assess your knowledge. This includes testing in the form of multiple choice questions and spaced repetition flashcards and things of that nature, but should also include self-pimping: you need to learn the skill of asking yourself the same questions that a harsh attending would ask of you.

As a deliberate learning exercise, ask yourself what it would take for your differential considerations to be plausible. Sure, this low-ish density collection is probably a chronic subdural hematoma or hygroma. But what would it take for you to consider a subdural empyema? Did you look at the mastoid air cells and paranasal sinuses?

Be Proactive

Don’t wait until somebody tells you to read about something to learn something, you already probably know the things that would’ve helped because you know the things that would’ve meant a better performance today: which pathological terms you didn’t understand, which body parts you had no clue about, which differentials were totally beyond your fund of knowledge.

Yes, it’s good to get through some kind of comprehensive entry-level text on your first rotation and to do whatever else people ask you to do, but it’s also worth learning about the things that are relevant to you now before you make the same mistake twice. Every diagnostic consideration raises its own series of differentials and potential complications.

Acknowledge the gaps and work to fill them every day. Adding the fruits of that labor to an Anki deck is probably an easy right move. Doing it continuously will remove a lot of the friction and build-up that makes us otherwise never quite get around to it.

Excuses Are Generally a Waste of Time

There’s a blurry line between explaining yourself to improve your approach and making excuses for your unavoidable lack of experience or inevitable mistakes.

Unless you want to explain your reasoning in order to have somebody correct your faulty reasoning, it usually doesn’t matter why you’re wrong. Not seeing things is just part of the learning process. Making the finding but reaching the wrong conclusion is often a teachable moment, but many mistakes are just a matter of reps. We all know that satisfaction of search and anchoring are big biases, so your attending doesn’t need you to explain why you didn’t notice something. The miss speaks for itself.

If you want to know why you’re wrong, then keep talking. Otherwise, let’s move on.

Reasonable Thoughts

Common sense and Bayesian updating are perhaps the most critical skills for medical critical thinking.

Base rates matter. They matter so much.

Common things are common. Weird presentations of common things are usually still more common than rare things. And rare things often only become reasonably plausible when their pretest ability becomes higher in context.

For example, intramedullary lymphoma is quite rare. But it would make more sense as a consideration for spinal cord pathology in a patient with new weakness if the patient has a known widespread lymphoma than if they just, say, had a flu shot.

Common sense and context awareness would prevent many diagnostic blunders.

Separate Content from Source

You can learn from every attending, even the bad ones.

Avoid their mistakes.

Finally, It’s OK That It’s Hard.

Difficulty and challenge aren’t bad, they are a critical part of human flourishing.

If you’ll excuse the crotchety-old-man moment, I think many of us have gotten into a mindset where we feel that the things people ask of us are an impediment to us living our best life, that hard work is intrinsically unfair, that anything even the slightest bit tedious is scut.

Not only is all this wrong–and trust me it’s not just because I’m getting older–but it’s also unhelpful.

There are certain parts of the world that we can change and certain parts that we can’t. The reality is that even the best careers have boring, tedious, and even unfair parts. We can’t have the good parts of a meaningful career if we are too quick to reject every part that doesn’t spark joy.

The first pile-on lawsuit against Radiology Partners has arrived: UnitedHealth’s original 2023 lawsuit against RP for an alleged “pass-through billing scheme” wrapped up this fall, and Aetna just filed their own Christmas present on December 23.

For those curious about how that United lawsuit played out, here are my three posts covering that story:

1. United against Radiology Partners
2. United is Still Fighting Radiology Partners
3. Counting Chickens: RP loses its windfall award from United

They provide a helpful backdrop of what’s happening now.

In the first part of its suit, Aetna alleges the same pass-through billing scheme:

In phase one of the scheme, Radiology Partners identified [its RP-owned practice] MBB as having the most lucrative in-network contracts with commercial payors in Florida, including Aetna, and began using MBB’s name and Tax Identification Number (“TIN”) to bill for services performed by all its “affiliated” Florida radiology groups. Radiology Partners’ use of MBB’s TIN to bill for services performed by other radiology groups misrepresented that MBB—as opposed to another radiology group with its own separate in-network contract—performed the services billed.

Lots of businesses merge or sell to do this legally (barring antitrust concerns).

The issue here is that RP wants to have it both ways. Each RP-owned practice retains its initial identity despite being functionally owned by RP. Part of this is to get around laws barring the corporate of medicine in some states. These groups maintain their original Tax ID and payor contracts while RP has operational control and its specified share of the profits. You don’t get to say each group is an individual “physician-owned” private practice on the one hand and then funnel all the billing through your best contracts as if every RP-owned practice was in fact one company. They’re either separate companies or they’re not.

By 2022, MBB was submitting significantly more claims to Aetna than it had historically because of Radiology Partners’ scheme. But when asked about this increase in claims volume, MBB deflected Aetna’s inquiries. Ultimately, Aetna terminated MBB’s in-network contract, causing MBB to go “out-of-network” with Aetna. The other radiology groups implicated by Radiology Partners’ scheme remained “in-network” with Aetna, however.

The cancellation of this contract seems like an important distinction with the United lawsuit. In that case, United unilaterally started paying RP under a different contract, which violated the terms of their original agreement dating back to 1998. So when the arbitration panel told both parties to just go away, they stated both parties got nothing because of their “breaches of the 1998 Agreement” and “other acts and omissions.” We’ll have to see what RP’s rebuttal will be, but it’s not clear here that Aetna made the same mistake as United of violating their contract. In the United case, the panel didn’t go into details but didn’t seem to like RP’s behavior (e.g. those breaches, acts, and omissions resulted in the panel vacating an almost $100 million interim award). If Aetna didn’t make a mistake, then presumably RP’s similar behavior here standing alone is less likely to result in just another mulligan.

But that canceled contract led to the second part of the claim, which is an equally egregious-sounding scheme of abusing the independent dispute resolution (“IDR”) process used to adjudicate out-of-network claims:

As an out-of-network radiology provider, MBB’s claims were now subject to the No Surprises Act (“NSA”), 42 U.S.C. §§ 300gg-111, which is intended to protect patients from surprise medical bills when, for example, they unwittingly receive services from out-of-network providers (such as MBB) at in-network hospitals. The NSA does not apply to in-network providers.

Rather than properly bill the services provided by Radiology Partners’ other radiology practices through those groups’ existing contracts with Aetna, the Defendants continued to bill all services through MBB, using MBB’s TIN. This, too, was a material misrepresentation that caused Aetna to pay MBB funds to which it was not entitled.

Defendants wanted to take even more from Aetna and its plan sponsors. To do so, Defendants initiated tens of thousands of arbitrations under the No Surprises Act’s independent dispute resolution (“IDR”) process for services that were provided by the Radiology Partners-controlled medical groups that had—and still have—in-network contracts with Aetna. These arbitrations were all initiated based on Defendants’ misrepresentations that they were for medical services provided by MBB. In truth, they were for medical services provided by other medical groups who had contracts with Aetna, rendering those services ineligible for arbitration under the NSA.

Now, MBB itself should have been using the IDR. That’s how it’s supposed to work, and if they still made great money via that process, so be it. The Brookings paper below suggests that the outcome of IDR being higher than typical market rates has been pretty common so far. What’s hard to imagine is what plausible argument RP has for submitting claims for work performed by its other Florida radiologists through the IDR process when those other groups had contracts in force.

If you’re employed by group X and working for group X and group X has a contract with Aetna, I don’t see how you pretend you’re out of network and bill through group Y, which does not employ you. If someone with billing expertise wants to weigh in, I’m very curious. The answer will probably help inform how many more of these lawsuits we should expect to see.

As Aetna (and others) point out:

As scholars studying NSA IDR data recently noticed, Radiology Partners and three other private-equity-backed provider groups have accounted for “a large and disproportionate share of IDR cases.” In fact, Radiology Partners is responsible for over 90% of all IDR cases involving claims for professional radiology services.

The referenced work is “A first look at outcomes under the No Surprises Act arbitration process” from Brookings, which noted that four companies (TeamHealth, SCP Health, Envision, and Radiology Partners) generated 74% of the studied IDR claims. RP is apparently responsible for over 90% of radiology claims despite a market share of probably no more than 10%.

For those who aren’t very familiar with this part of the No Surprises Act, the paper breaks down the process well. To be clear, the NSA is a great example of well-intentioned but totally broken legislation, and the IDR process is a mess.

When you see a news story that a handful of private equity companies are responsible for the vast majority of IDR claims, it makes you wonder: Is it just because they bought the groups with the best contracts and therefore those most likely to be dropped by insurers in the aftermath of the NSA? Is it because their practice-consolidation approach results in higher costs that the payors are unwilling to pay leading to these subsequent reimbursement fights? Are they just better at playing the game and going after the unscrupulous payors? Or–as the case may be here–are we looking at a combination of likely all of these things plus potentially/allegedly a bunch of fraud, bypassing in-force contracts to funnel unrelated work through the arbitration process in bulk in order to hide what should be lower-paying work? What a mess.

Ultimately, this is another emotionally unfulfilling conflict. Aetna is not a “good guy” here. There are no good guys. The No Surprises Act means that an insurance company has the option to drop a high-paying legacy contract and force a group to go out of network as a negotiating tactic to renegotiate rates and push reimbursement down. The Brookings’ analysis suggesting that recent IDR awards have so far trended toward the higher pre-NSA out-of-network surprise bills and not the lower dubiously-defined qualifying payment amount (QPA) doesn’t change the fact that the payors have been using it as a bullying tool in their arsenal to pay less. That RP may have deserved it here is only part of a much larger depressing story.

One imagines Aetna has learned from recent events and likes its chances.

One also wonders how many more payors in how many more states might be polishing up additional suits for 2025.

I believe in the importance of thriving independent private practices for the field of radiology. True private practice–where doctors control the organization, are responsible to their peers and patients, and earn the full fruits of their labor–is the benchmark that sets the market and provides the anchor against exploitation from unscrupulous employers.

My group, like most groups in this market, is hiring. Here are 10 more 100%-independent radiologist-owned private practices across the US that are recruiting. If you’re in the market for a new position, consider reaching out with your CV. (Click the triangles for more information.)

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Eastern Radiologists

(Greenville & Coastal North Carolina)

Eastern Radiologists is a private practice in Eastern North Carolina that is physician-owned and operated and seeking to hire multiple radiologists due to growth and retirement. The well-established private practice serves a large geographic region through 14 area hospitals and several state-of-the-art imaging centers. Support is provided by nearly 70 subspecialty radiologists.

Currently seeking candidates with the following training:

• Pediatric Imaging
• Breast Imaging
• Neuroradiology
• Body Imaging
• Nighthawk/Overnight
• General Diagnostic Radiology
• Vascular/Interventional

Details:

• Positions are available in Greenville and other coastal communities in Eastern North Carolina.
• Most are partnership track positions which include evening and weekend call responsibilities, but other employment options can be considered. Employment positions can be customized to fit desired schedule/income. Internal moonlighting is available for extra income.
• Great benefits, competitive salary including profit sharing and bonus, generous vacation and paid family leave, and business/educational discretionary account.
• Sign-on bonus

Learn more at https://www.easternrad.com.
Contact: Erica Askew at easkew@easternrad.com

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RAPA

(Central Arkansas [Little Rock, Conway, Searcy, and Pine Bluff] & Northwest Arkansas)

40+ radiologists covering 20+ sites (hospitals + clinics) with a multi-subspecialty mix of inpatient, outpatient, and ED imaging.

• Robust reading room assistants and IT presence to promote peak efficiency
• Unified Clario reading list, Inteleviewer PACS, Powerscribe dictation (no switching stations or PACS to read other sites)
• RadAI automated impressions to improve efficiency.

Partnership track – Central Arkansas (Little Rock, Conway, Searcy, and Pine Bluff) and Northwest Arkansas:

• 1 year to partnership for onsite positions
• 10 weeks vacation + 1/2 day off per week on average for partners
• Highly competitive compensation combined with low cost of living
• Internal moonlighting options to boost income
• Robust CME allowance, signing and moving bonuses, full benefits
• Many work-from-home shift options
• Minimal after-hours requirements – overnight shifts are fully staffed with telerads

Employee track:

• General radiology, mammography, and other options available
• Fully remote, hybrid, or on-site options available
• Flexible scheduling
• Competitive salaries
• Robust CME allowance, signing and moving bonuses, full benefits

Greatest needs are IR, mammography, body imaging, MSK, and nuclear medicine, but all subspecialties and general radiologists are welcome.

Learn more at http://rapaxray.com/
Contact: recruitment@rapaxray.com and Dr. Brandon Kelly at bkelly@rapaxray.com

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Radiology Associates of Ocala

(Ocala, Florida)

A growing Central Florida private practice, rare for the region, with 70+ radiologists looking for an on-site general radiologist.

• Practice owns multiple imaging centers, generating technical fees and rental income for partners.
• New business ventures of software development and a separate Telerad company.
• Optional internal moonlighting available. Nights are covered by dedicated internal nighthawks.
• Option to rotate/vacation in the US Virgin Islands at a practice-owned timeshare at the St. Thomas Ritz.

Remote Partnership:

• 1-year track, professional-fee exclusive, 226 shifts with 10 weeks vacation and 8 weekends, $500-700k+

On-site Partnership:

• 3-year track, no partnership tiers, additional income from technical fee billing, management revenue, and real estate. Nominal buy-in and equal call/PTO/scheduling for pre-partner and partners. 14+ weeks vacation (~185 shifts/yr), $800k-1mm+

Learn more at https://raocala.com.
Contact: Dr. Vivek Kalra at Vivek.Kalra@raocala.com

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Mecklenburg Radiology Associates

(Charlotte, North Carolina)

Established in 1917 and fiercely independent, MRA is a well-respected subspecialized practice of 60 radiologists and growing. They especially take pride in their group culture (seriously, there are some really nice people in that group including one of my old senior residents).

Partnership track:

• 3-year partnership track with 8 weeks of vacation per year
  $400K starting salary and an additional $75K sign-on bonus ($125K with 2+ years of experience)
• On-site daytime hospital and imaging center coverage. Hybrid evening and weekend call coverage, including the option to read from home.
• Available positions: Breast, Body, Cardiovascular, Neuro, Light IR, MSK, Nuclear Medicine, and General

Employee track:

• Fully remote, hybrid, or on-site options
• Competitive salary
• Available positions: General, Overnight ER, Swing Shift ER

Learn more at www.meckrad.com/recruitment.
Contact: Charlene Eichinger at ceichinger@meckrad.com

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Radiology and Imaging Specialists

(Central Florida: Lakeland/Winter Haven, SW Orlando, Bradenton)

Independent and long-standing group covering a diverse mix of financially sound hospital partners, outpatient imaging centers, an ASC/OBL, clinics, and a multi-specialty group. 50+ radiologists and 10+ midlevel providers. In-house and experienced IT, Credentialing, HR, and Admin team including dedicated Radiology Liaison support 24/7/365.

Recruiting for Body, Breast, Cardiac, Neuro, IR, and General.

Partnership Track:

• 1-year track
• 10 weeks of vacation
• Sign-on bonus
• Internal moonlighting available but not required
• Full benefits including CME allocation

Employee or Contractor:

• Flexible scheduling: Hospital (ED/IP) or outpatient coverage options available
• Fully remote, hybrid, or on-site depending on location(s) and coverage schedule desired
• Competitive compensation

Learn more at http://risimaging.com.
Contact: Alice Varnadore, Executive Assistant at avarnadore@risimaging.com

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South Texas Radiology Group

(San Antonio, Texas)

STRG is a well-established, expanding, independent subspecialty practice of 70+ radiologists serving 15 hospitals, multiple freestanding ED facilities, and a large outpatient imaging practice (STRIC). Both onsite and remote positions are available.

STRG is a forward-thinking practice with a strong and cohesive culture. Multiple AI projects are in place and in progress to improve efficiency and quality. Internal moonlighting opportunities are available.

Shareholder Track:

• 18-month associate period leading to full partnership with board of directors membership.
• Equity within a large expanding outpatient imaging practice (STRIC)
• Competitive salary with excellent benefits package
• Onsite and work-from-home options for daily work and call
• Hiring across all specialties, with a current emphasis on Body Imaging and Cardiothoracic/Body

Emergency Radiology Track:

• 1 week on/1 week off (7/7) and 1 week on/2 weeks off (7/14) positions available
• Competitive salary with excellent benefits package
• Fully remote and onsite options available.

Learn more at https://stric.com/.
Contact: Waynea Finley at wfinley@strg-pa.com

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Midwest Radiology

(Minneapolis – St. Paul, Minnesota)

Large 175+ subspecialized practice with 17 weeks of vacation. Two-year shareholder track for new graduates and a one-year track with experience.

Positions (On-site):

Positions (Remote):

Learn more at www.midwestradiology.com.
Contact: Barry.Lindo@MidwestRadiology.com

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Grand Traverse Radiologists

(Traverse City, Michigan)

Established in 1938, GTR is a 100% physician-owned and operated private practice in a four-season resort town on the bays of Lake Michigan.

• High compensation and 12 weeks vacation
• Post-call weekend days off
• Internal moonlighting available
• Positions/partnerships are on-site, but multiple shifts can be done from home.
• Collegial and youthful group with an average age under 40. All partners are equal.
• Hiring for growth. Lists are caught up!

Needs: Body, Breast, ER/General, and IR

Learn more at https://www.grandtraverseradiologists.com
Contact: Dr. Anthony Livorine at alivorine@gtradiologists.com

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Hudson Valley Radiologists

(Poughkeepsie, New York)

A congenial team of 25 sub-specialized radiologists in New York’s scenic Hudson Valley that understands the importance of work-life balance. Since the 1970s, HVR has been respected in the community and known for its entrepreneurial spirit and excellence in patient care, currently providing services to five local hospitals and multiple outpatient imaging centers.

Learn more at https://www.hvrads.com/
Contact: Dr. Evan Kurz at esk@hvrads.com

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Inland Imaging

(Washington, Oregon, Montana)

Inland Imaging is a 120+ radiologist-owned private practice proudly serving multiple outpatient, clinic, and hospital sites throughout the Inland Northwest region. We own and operate one of the first outpatient interventional labs in the West in addition to 7 outpatient imaging centers.

Our practice:

• Sub-specialty interpretations available across all locations.
• All studies are accessible on a common PACS system, one common voice recognition system, and one common worklist
• Internal Nighthawk System providing final interpretations on all ER, STAT, and Inpatient Exams. 24/7 Neuroradiology Coverage and IR Call Coverage.
• 2-year Partnership Track.
• Full-Time Radiologist Average Time Off = 15 weeks with the ability to decrease or increase total time off.
• Average after-hours obligations = 9 weekends per year and 22 evening/swing Shifts.
• Salary Range – $450,000 – $600,000
• Full Benefit Package including health, life, vision, dental, disability, and life.
• 401k match, profit sharing contribution, and cash balance plan.
• Hybrid Work Options

Current Openings:

• Remote overnight ER
• Neuroradiology (choice of Spokane, Seattle, Walla Walla, Tri-Cities, or Missoula)
• Washington
  • Tri-Cities
    • Breast
    • Neuro
    • MSK
  • Spokane – Pediatrics
  • Moses Lake – General/Breast
  • Colville – General/Breast
• Montana
  • Hamilton – General/Breast
• Oregon
  • Pendleton – General/Breast

More information about these positions can be found on our Independent Radiology listing.

Learn more at https://inlandimaging.com/careers
Contact: Sarah Russell, CEO at srussell@inlandimaging.com

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If you’re a group looking to advertise, get in touch. The monthly post here is limited to just 10 groups at a time, but in August I launched Independent Radiology as a resource for the broader community, a dedicated private practice radiology job board with 100+ groups so far. If you’re in the market, please also check it out for your job-hunting needs.

From “The U.S. Radiologist Workforce: AJR Expert Panel Narrative Review,” just published in AJR:

Between 2014 and 2023, the number of radiology practices decreased by over 17%, while the number of practices with 25-49, 50-99, and 100 or more radiologists grew by 33%, 126%, and 349%, respectively.

Consolidation in action. An arduous regulatory climate, challenging payor relationships, tumor-like health network/hospital/system growth, and the increasing volume and intensity of after-hours work all favor a smaller number of larger groups. Scale to combat scale.

Imaging provider Akumin’s new post-bankruptcy CEO, in an interview with Radiology Business, describes their new owner, Stonepeak, which took control of the company after swapping ~$470 million in debt for equity and dropping an extra $130 million as part of a Chapter 11 bankruptcy:

Stonepeak has a longer-term investment horizon compared to traditional private equity, which typically holds assets for three to five years. For Stonepeak, eight to 12 years has been their typical investment horizon. Our relationship has gone really well with them because, once they own an asset in this space, they stay with it for a long time.

In this industry, a decade is considered a “long time.” I guess that’s true: It took me a decade after college to become a radiologist.