Healthcare providers and health systems should keep using appropriate use criteria-based exam ordering systems
The American College of Radiology® (ACR®), a leading voice in the field of radiology, reiterates its support for the Protecting Access to Medicare Act (PAMA) appropriate use criteria (AUC) program.
In the 2024 Medicare Physician Fee Schedule (MPFS) final rule, the Centers for Medicare and Medicaid Services (CMS) cited the value of the AUC program in optimizing medical imaging care but temporarily paused the AUC program to allow Congress to make legislative updates to facilitate implementation.
ACR urges providers, including radiologists, and medical practices to continue leveraging AUC-based clinical decision support (CDS) exam and procedure ordering systems while this process moves forward.
"The AUC program has not been repealed, and with a legislative update on the horizon, ACR urges health systems, hospitals and practices to continue using the program to ensure appropriate imaging for patients," says Dr. William T. Thorwarth Jr., ACR CEO. "We are committed to working collaboratively with Congress and CMS to ensure the success of the AUC program, contributing to improved patient care and meaningful cost savings."
The PAMA AUC program was established to move the healthcare industry toward value-based care, alleviate Medicare spending on low-value advanced imaging procedures and offer a more credible alternative to cumbersome prior authorization programs. A key facet of the AUC program is its use of physician-developed, transparent, evidence-based criteria in CDS ordering systems to guide providers in determining a patient's advanced imaging needs.
“The AUC-based clinical decision support approach optimizes patient care and yields numerous benefits, including enhanced diagnostic accuracy, reduced delays in access and improved health outcomes,” said Jacqueline A. Bello, MD, FACR, chair of the ACR Board of Chancellors.
The 2024 MPFS final rule, released in November, paused implementation citing challenges related to the real-time claims processing aspect of the statute, expressing concerns about the inability to automatically identify claims exempt from AUC consultation.
ACR acknowledges the barriers to implementation and calls for a legislative fix to address the real-time claims processing requirement. ACR sees a clear path forward for the PAMA AUC program through a simple statutory change to the law and is actively engaged with Congress and CMS to modernize the program, advocating for the removal of the real-time claims processing requirement to propel this essential quality program forward.
ACR highlights the importance of the AUC program as a preferable option over alternatives such as radiology benefits managers and prior authorization. Unlike these alternatives, which may strip medical decisions from doctors and result in delays or denials of lifesaving care, the AUC program empowers physicians to make real-time informed decisions for the benefit of their patients. Additionally, CMS estimates that the utilization of AUC could lead to potential annual savings of $700 million for the Medicare program.
“ACR remains dedicated to fostering healthcare that prioritizes evidence-based, patient-centered care,” said Dr. Thorwarth. “ACR invites stakeholders across the healthcare spectrum to join in supporting legislative improvements that will further strengthen and streamline the AUC program, ensuring its continued success in enabling appropriate imaging and optimizing patient care.”Medical Groups Tell Anthem to drop OON Penalty
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