Is Your Traditional Medicare Doctor Ordering Unneeded Medicare CT Scans, MRIs?

[GailL1]

If so . . . . . some changes could occur.

FROM CMS:  CMS - Appropriate Use Criteria Program

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Examples of such advanced imaging services include:

• computed tomography (CT)
• positron emission tomography (PET)
• nuclear medicine, and
• magnetic resonance imaging (MRI)

Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction,would have to consult a "best practices" guide of "Appropriate Use Criteria" (AUC) for ordering such a medical tool in the assessment of a condition.

This law required that doctors consult this clinical guide set by the medical industry before Medicare will pay for many common exams for enrollees.

Health care providers who go way beyond clinical guidelines in ordering these scans (the 5% who order the most tests that are inappropriate) will, under the law, be required after that to get prior approval from Medicare for their diagnostic imaging.

Kaiser Health News 08/14/2019 - Trump Administration Hits Brakes On Law To Curb Unneeded Medicare CT...

Now five years after Congress passed  this law to reduce unnecessary MRIs, CT scans and other expensive diagnostic imaging tests that could harm patients and waste money, federal officials have yet to implement it.  It was suppose to have been fully implimented by January 2018 but the Trump administration has delayed it until January 2020.  But even then, there would be a testing period for a couple of years during which Medicare would still pay for the ordered test if the doc does not comply. 

CMS also said it won’t decide until 2022 or 2023 when physician penalties will actually begin.

Critics worry the delays come at a steep cost: Medicare paying for millions of unnecessary exams and patients subject to radiation for no medical benefit.

The law applies to doctors treating patients enrolled in the traditional fee-for-service Medicare system. Health insurers, including those that operate the private Medicare Advantage plans, have for many years refused to pay for the exams unless doctors get authorization from them beforehand. That process can take days or weeks, which irks physicians and patients.

Not all Medicare imaging tests will be subject to the requirements. Emergency patients are exempt, as well as patients admitted to hospitals. CMS has identified some of the most common conditions for which doctors will have to consult guidelines. Those include heart disease, headache and pain in the lower back, neck or shoulders.

A growing number of health systems have used clinical guidelines to better manage imaging services.

And, oh yes, other country's controlling their health care cost also rely on such protocols.

Read more at the links provided above ~

This affects what all seniors in Medicare pay for their Part B premiums - if inappropriate use is held down for these test based on clinical guidelines, it will help to hold down these premium increases.

For now - the mandate is on hold pending further input and study - but I think it is going to come - we have to start reigning in health care cost using best practices.

Cross posting this on both the Medicare and Insurance Board and the Politics and Current Events Board for wider audience viewing.