18 Apr CMS May Require Some Doctors to Get Pre-Authorization for Imaging

Diagnostic Imaging | High utilizers of advanced medical imaging beware: the Medicare Payment Advisory Commission (MedPAC) just voted 15-1 this month to recommend to Congress that the top tier of referrers of advanced medical imaging should get prior authorization first.

The imaging studies include MRI, CT, PET scans, and nuclear medicine, with the stated intent of ensuring that outliers are appropriately using imaging.

The idea is that the change takes aim at high referrers who do so inappropriately. CMS would divide providers into two categories: those who order substantially more studies than their peers, and those who don’t. For the latter category, no authorization requirements will be needed when ordering imaging studies. For the high utilizers, those who are found by CMS to have a low rate of inappropriate use would only be subject to prior notification for these advanced imaging studies, while the providers deemed high referrers for inappropriate imaging use would be required to obtain prior authorization from CMS.

Ariel Winter, a MedPAC senior analyst noted that 10 percent of physicians ordered 50 percent of the volume of advanced studies. And a “significant number” of the 10 percent were self-referring physicians. The recommendation for prior authorization does not focus on just self-referrers, but rather any high utilizer in the top bracket.

While implementing the recommendation, CMS aims to minimize wait time for patients as well as the administrative burden for physicians, Winter said.

He estimated that CMS would save up to $50 million the first year, and up to $1 billion over five years by requiring authorization from this set. In addition to the money saved, patient exposure to unnecessary radiation would be reduced.

This was one of four recommendations passed at the April 7 MedPAC meeting in Washington, DC. MedPAC advises Congress on Medicare and Medicaid (CMS) issues. The other recommendations, passed unanimously, include:

• accelerating and expanding efforts to package discrete services in the Physician Fee Schedule into larger units for payment;

• applying a multiple procedure payment reduction to the professional component of diagnostic imaging services provided by the same practitioner in the same session;

• reducing the physician work component of imaging and other diagnostic tests ordered and performed by the same practitioner.

The recommendations were made to improve payment accuracy and appropriate use of ancillary services.

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