By Aine Cryts
Jan. 1, 2020, is the first day referring physicians were required to consult appropriate use criteria (AUC) for advanced imaging services that are delivered in outpatient settings under the Protecting Access to Medicare Act (PAMA), which became law in April 2014.
Radiology practices need to pay attention to PAMA because their revenue is “at risk,” Sean McCormick, MD, physician informaticist at Nashville, Tenn.-based Change Healthcare, which provides healthcare technology products and services, tells AXIS Imaging News. “Ultimately, payment of these claims will be withheld if they do not contain the evidence that AUC was consulted when selecting the service,” he says.
(MedPage Today reported that the launch of the program has been delayed a few times and that imaging claims won’t be rejected—even if they’re improper—until next year. It also reported that there’s no firm deadline for additional penalties.)
At risk for radiology practices are its revenue—and patient relationships—if they can’t provide imaging services to patients without AUC, McCormick tells AXIS. That’s why he advises radiology groups to “take a strong change-management approach to PAMA and partner with their referring partners on education and compliance.”
AXIS Imaging News recently discussed PAMA compliance and its impact on radiology groups with McCormick. Here’s what he had to say.
AXIS Imaging News: What’s the latest on PAMA from a rule-making point of view?
Sean McCormick: In the 2020 rule-making cycle, the Centers for Medicare and Medicaid Services (CMS) will define how and when it will link the consultation requirement to payment and the determination of outliers who will ultimately be subject to prior authorization.
AXIS: What’s your advice for radiology groups to ensure compliance?
McCormick: The compliance requirement opens up opportunities for radiologists to open a dialogue related to appropriate imaging and value-based imaging with their referrers through imaging decision-support. An imaging decision-support program can be the foundation for programs that exempt referring providers from the prior-authorization process, thus delivering more appropriate care in a more efficient manner.
AXIS: What should radiology groups do during the educational and operations testing period this year?
McCormick: Through the end of 2020, we’re in a CMS-defined mandatory educational and operational testing year. During this period, practices should be educating their referral base on the requirements. For example, practices could consider automated-engagement solutions to educate referring physicians and track their registration for a clinical decision-support tool solution.
In addition, healthcare organizations and radiology practices must develop organization-wide compliance strategies that consider the risks of noncompliance and ensure that there’s a clear pathway toward compliance when payment is impacted. Implementing a robust change-management program that includes referring provider education, automated ongoing communication, compliance evaluation, and, when necessary, remediation will be critical to revenue defense.
AXIS: What’s next with PAMA as far as the rule-making process is concerned?
McCormick: With PAMA, we’ll learn more about payment and outlier calculation as rule-making progresses this year. All stakeholders are aware of the benefits of AUC when making care decisions. The key will be to ensure any component of the program that is linked to payment is seamless and accurate. We’ll be monitoring the rule-making process closely as it begins in July.
AXIS: Are healthcare organizations prepared?
McCormick: We know from our client data that a high percentage of healthcare provider organizations have enabled imaging decision-support within their EHR workflows for the purpose of PAMA compliance and as part of a larger imaging-stewardship initiative. These same organizations have begun to configure their billing systems and outbound interfaces with the PAMA claims data.
In addition, many of the leading ambulatory EHRs have integrated a decision-support tool. At RSNA ’19, we launched our Open Access website, which gives providers no-fee access to AUC, and this covers all advanced imaging. It also satisfies the requirements of the program and serves as a reference tool.
Aine Cryts is a contributing writer for AXIS Imaging News.