July 18, 2023

CMS Proposes Pausing Imaging Appropriate Use Criteria Program

The Centers for Medicare and Medicaid Services (CMS) proposes in the 2024 Medicare Physician Fee Schedule (MPFS) proposed rule to pause the implementation of the Protecting Access to Medicare Act (PAMA) imaging appropriate use criteria (AUC) program. CMS continues to have concerns with the real-time claims processing aspect of the statute, stating “…we have exhausted all reasonable options for fully operationalizing the AUC program consistent with the statutory provisions…” The proposal says more time is needed to reevaluate the program to ensure that imaging claims are not inappropriately denied.

The PAMA imaging AUC program, passed by Congress and signed into law in 2014, requires ordering providers to consult AUC developed by provider-led entities through a clinical decision support mechanism (CDSM) when ordering advanced diagnostic imaging, including CT, MR, PET and nuclear medicine, for Medicare Part B patients. It was designed as an alternative to prior authorization to decrease inappropriate imaging. If the program were to be fully implemented, payment for imaging services that do not contain the appropriate AUC consultation information on applicable claims would be denied. The program has been operating in an “educational and operations testing period” without payment penalties in place since Jan. 1, 2020. The proposal to pause the program includes pausing the ongoing educational and operations testing period.

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.”

Despite the implementation barriers necessitating the reevaluation of the program, CMS recognizes the value of AUC to improve utilization patterns for Medicare beneficiaries in the proposed rule. The agency indicates that utilizing AUC to ensure that patients receive the right imaging at the right time would “inform more efficient treatment plans and address medical conditions more quickly and without unnecessary tests.” The rule states that this could result in potential savings to the Medicare program of $700 million annually.

The American College of Radiology® (ACR®) recognizes the significant issues CMS faces with the real time claims processing aspect of the AUC program and the potential impact on members if claims are denied inappropriately. The College is working with Congress to streamline and modernize the PAMA AUC program, including the removal of the claims-based reporting requirement, to allow the program to move forward and ensure Medicare patients receive the right imaging tests at the right time. CMS also acknowledges the value of clinical decision support in the proposed rule to “improve the quality, safety and efficiency and effectiveness of health care,” and encourages the continued voluntary use of clinical decision support tools.

For more information, contact Katie Keysor, ACR Senior Director, Economic Policy.