Here Come More Rules By Medicare

Are rules good or bad? Well that depends on how good your medicine is, and whether you’re involved in the business of healthcare. Its easy to order a test than rely on a physical examination finding, is it not? What compensates a physician more, even if she is just an employee? The several minutes performing a very detailed and thorough lung examination for a patient who has a cough, or an x-ray? The fact that asymmetrical chest wall expansion has 90-95% sensitive and specificity for ruling in/out a suspicion of a consolidation for pneumonia, or a simple chest x-ray? What’s easier to do – get an echocardiogram in a student athlete who presents for a sports physical examination and has a murmur, or rather spend time doing the maneuvers that help differentiate hypertrophic cardiomyopathy from an innocent murmur? Even so, if a physician relies on his physical examination and foregoes an echocardiogram for the murmur and later the family learns, perhaps the hard way, of their prodigal son or daughter dying instantly during a sports activity, there’s a high likelihood that a physician will be put on trial, sued but worst of all lose his license. Then there are those physicians, who will order imaging to prevent the latter from happening or simply, just order the tests because they can.

Well, that’s about to change, at least for Medicare patients. Clinicians will now be forced to follow the “appropriate use criteria (AUC) for cardiac imaging because published literature reveals that rates of “rarely appropriate testing in various types of imaging” may be at an all-time high. Centers for Medicare and Medicaid (CMS) introduced “Protecting Access to Medicare Act (PAMA)” in 2014 which was to introduce a new framework, rather algorithm, for applying the AUC. To comply with such requirements, clinical decision-support mechanisms (CDSM) have been introduced into EHRs and as of 2018, PAMA was supposed to require ordering physicians to consult AUC using a CMS-approved CDSM when ordering advanced imaging procedures. These procedures include CT, PET, nuclear medicine scans and MRIs.

The program requires that at the time a practitioner orders an advanced diagnostic imaging service for a medical beneficiary, he, or the clinical staff acting under his direction, will be required to consult a qualified CDSM, which will give access to the AUC. Those whose ordering patterns are considered outliers will be subject to prior authorization. The claims that fail to append such information will be denied.

In theory, this sounds great, but in reality, it’s the government enacting more control over decision making. I do agree that unneeded tests are ordered, however, this enactment is an avenue through which the government can set more AUC for additional testing, such as labs, simple imaging, and even possibly medications. Private insurers tend to follow Medicare rules and regulations when it comes to reimbursement and they will soon follow. I suppose we will see how things pan out.

Since July 2018, the program has been operating under a voluntary participation period and starting in January 2020 this program will operate in an Education and Operations Testing Period. It won’t be until January 2021, when this program is to be fully implemented.

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