After several years of struggles by the Centers for Medicaid and Medicare Services (CMS) to implement a Medicare program requiring the consultation of appropriate use criteria (AUC) via a clinical decision support mechanism when outpatient advanced diagnostic imaging services are ordered, CMS has proposed a suspension of the program. The agency made the announcement in the release of its 2024 proposed Medicare Physician Fee Schedule rule. Most of the headlines after the CMS suspension announcement indicate that AUC is a dead article. The American College of Radiology (ACR) continues to hope for a different fate for the program.
The ACR said in a statement released this week that it believes that CMS continues to recognize the value of AUC to improve utilization patterns for Medicare beneficiaries. The ACR appreciates that CMS continues to acknowledge that AUC can "inform more efficient treatment plans and address medical conditions more quickly and without unnecessary tests."
ACR's statement noted that CMS acknowledged the value of clinical decision support in the proposed 2024 rule to "improve the quality, safety and efficiency and effectiveness of health care" and that CMS supports the continued voluntary use of clinical decision support tools.
In 2014, the U.S. Congress enacted the Protecting Access to Medicare Act (PAMA) that, in part, directed CMS to establish a program to promote appropriate use of advanced diagnostic imaging services. The program is designed to promote appropriate outpatient utilization of AUC for advanced diagnostic imaging services (CT, MRI, and nuclear medicine/PET) when ordered for Medicare outpatients. CMS approved various sets of appropriate use criteria that have been developed by provider-led entities selected by CMS, such as national professional medical specialty societies like the American College of Radiology. But never was a requirement put in place to require ordering physicians to consult AUC via a clinical decision support mechanism. One wonders if it will ever come to that.
ACR's long-standing support for AUC is grounded in the need to offer an alternative to CMS requiring pre-authorization for all advanced imaging. The ACR still believes that AUC consultation allows physicians to choose the best test for patients based on those patients' individual circumstances, and not the dictates of payors.
The AUC program may appear to be dead, but ACR takes solace in the possibility that the AUC program could nevertheless still become viable and effective. ACR continues to believe that the AUC program is the best route to ensure that Medicare patients "receive the right imaging tests at the right time." And they believe CMS policymakers agree.
I'm not sure the AUC program will see life again, but only time will tell.
CMS has faced continual challenges implementing the PAMA AUC program, specifically related to the real-time claims processing requirement. The 2024 MPFS proposed rule states, '...the real-time claims-based reporting requirement prescribed by section 1834(q)(4)(B) of the Act presents an insurmountable barrier for CMS to fully operationalize the AUC program.'
This article is presented for informational purposes only and is not intended to constitute legal advice.
