Appropriate Use of Time? Medicare Rules for Advanced Imaging Orders Pose Prior-Auth Burdens
By Joey Berlin Texas Medicine February 2020

An effective way to cut down on overuse of potentially harmful imaging, or a prior authorization-esque burden on physicians who order needed tests?

Texas physicians see Medicare’s “appropriate use” system for advanced imaging both ways.

As of Jan. 1, physicians ordering advanced imaging tests for Medicare patients must consult an electronic portal, which evaluates whether the test meets Medicare’s own “appropriate use criteria” for whether a test should be ordered. Then when the claim is filed, physicians must document that they checked the system and its determination.

During the 2020 educational and testing period, Medicare won’t deny claims if physicians don't document that system check, and physicians can override Medicare’s “appropriate use” determination and order the test anyway.

But beginning in 2021, physicians who fail to submit the required information could see their claims denied. Moreover, Medicare could then label doctors “outliers” in their test-ordering and subject them to prior authorization – the dreaded roadblocks that physicians say can unnecessarily hold up care.

The Texas Medical Association tried to warn the Centers for Medicare & Medicaid Services about the pitfalls of its appropriate use program in 2018, telling the agency that it carries “enormous process and cost burden” on physician practices and equated the program to using “a sledgehammer to crack a nut.”

“It’s just creating another barrier for patient care. It is going to delay care, and has the potential, if you get labeled an outlier, [to create] extra work by doing preauthorizations,” says Keller family physician Greg Fuller, MD, the former chair of the TMA Council on Health Care Quality. “This already is going to be extra work.”

But a number of the physicians who stand to lose out on payments once the system reaches full flower – namely, radiologists – support CMS’ approach.

Fort Worth radiologist Tilden Childs, MD, says the goal of the program is to help physicians order the right study.

“It will reduce an amount of inappropriate imaging by telling a physician, ‘Well, maybe there’s no imaging study that really fits your criteria for what you’re trying to evaluate. Consider some other way of evaluating,’ for example,” he said. “So it can reduce inappropriate utilization and thereby reduce the radiation exposure to patients, so it increases diagnostic efficiencies and saves money for the payers.”

 How “appropriate use” works

The 2014 Protecting Access to Medicare Act established the appropriate use program, which began with voluntary participation in July 2018. CT and PET scans, nuclear medicine, and MRIs are among the imaging procedures covered.

The criteria for ordering an advanced imaging test were developed by organizations CMS qualifies as a “provider-led entity,” defined on its website as “a national professional medical specialty society or other organization that is comprised primarily of providers or practitioners who … predominantly provide direct patient care.” Among the more than 20 entities listed on the CMS website are the American College of Radiology (ACR), Johns Hopkins University School of Medicine, and The University of Texas MD Anderson Cancer Center.

Beginning this year, ordering physicians must take the extra step of consulting Medicare’s predetermined test criteria through an electronic portal, called a clinical decision support mechanism, which evaluates whether the test order adheres to Medicare’s definition of appropriate use.

“Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization,” CMS says on the website. “Information on outlier methodology and prior authorization is not yet available.”

Because the year 2020 serves as an educational and operational testing period, claims “will not be denied for failing to include proper [advanced use criteria] consultation information,” CMS said on its website. But upon full implementation at the beginning of 2021, claims must include information about consultation of the appropriate-use system, including whether the system says the test met the criteria. “Claims that fail to append this information will not be paid,” the website says.

In written responses to questions from Texas Medicine, a CMS spokesperson said the agency “expects to learn more about the prevalence of imaging orders identified as ‘not appropriate’ under this program when we begin to identify outlier professionals.”

CMS expects to address identifying outliers and prior authorization more fully in its 2022 or 2023 rulemaking, the spokesperson said.

Unnecessary sledgehammer?

TMA maintains that the burden is too great. In a September 2018 letter to CMS, TMA made clear that its concern over Medicare’s appropriate use process isn’t just about time – it’s about cost, too.

“The administrative burdens include the costs to purchase or subscribe to specific proprietary [clinical decision support mechanism] products, the costs to build or incorporate software interfaces for those products, the costs of revising referral processes to ensure that the required information is transmitted from the ordering to the referring physicians, the costs to revise claim filing processes and software, and the costs for physician and staff training for both ordering and referring physicians,” TMA wrote. “We continue to be very concerned that the total cost of implementing these processes for all physicians far exceeds any possible benefit in the form of reduction in over-utilization.”

TMA added that if evidence exists “suggesting that specific Medicare providers are using advanced diagnostic imaging inappropriately,” Medicare’s mandates should be targeted specifically at them. “We continue to oppose adding material administrative burden on all physicians and providers to change the behavior of a minority who may be referring inappropriately,” TMA added.

Little Elm internist John Flores, MD, chair of TMA’s Council on Socioeconomics, says the patient comes first, and acknowledges that large amounts of money have been wasted on unnecessary testing. But “the proof’s in the pudding. We have to wait and see how [Medicare’s program] is administered and how our colleagues are able to use the system,” he said. “We’re already burdened with EHRs [electronic health records]. And now when I order tests, am I going to have to stop and go through this whole system and probably add 10 more minutes to my day per patient [that] I order a test on? That’s what concerns me: Is it going to be better, or is it going to be just another burden?”

If CMS denies imaging claims through the appropriate-use program, radiologists like San Antonio’s Zeke Silva, MD – chair of ACR’s Commission on Economics – stand to have trouble getting paid. But ACR supports Medicare’s appropriate use program, and Dr. Silva, while acknowledging the need to be mindful of added administrative burden on physicians, draws distinctions between the appropriate use process and actual prior authorization.

He notes prior authorization generally occurs after the patient has already left the office – after patient and physician collectively made a decision about the patient’s care, which is then unceremoniously undercut by a health plan.

But with Medicare’s clinical decision support system, he says, it’s possible for ordering physicians to have approval for a test wrapped up before the patient walks out the door.

“The physician is able to enter into the decision support mechanism information about the patient – which, if it’s done efficiently, is already populated,” Dr. Silva said. After completing the process, he says, “the physician feels pretty good that he or she has ordered the right exam,” and the patient, who still might be at the office, “feels confident that an informed decision has been made.

“Hopefully, and I want to be super-respectful of the referring physicians when I say this … there’s an educational component there,” Dr. Silva added. “We have a lot of studies for common conditions where the physician’s experience guides [test-ordering], as it should. But there are times when it’s an unusual diagnosis or an unusual clinical scenario where physicians can’t know everything, and maybe there’s an educational component there, some information that maybe can be gained going forward.”

So far, Medicare hasn’t made physicians jump through prior authorization hoops.

“The more hassle factor there is, [it’s] just another reason people will quit doing Medicare,” Dr. Fuller said. “If you’re spending time and staff cost, especially in primary care, when do you say, ‘Enough is enough?’”