Healthcare Technology Featured Article

May 12, 2014

Reading the Tea Leaves: Prior Authorization for Advanced Imaging Services Is in Our Future

Legislation is commonly proposed to change provider behavior; for example, as a way to decrease the number of orders for high-cost procedures and improve use of evidenced based medicine. That is the point of some provisions of the newly enacted Protecting Access to Medicare Act of 2014. It delays the payment cuts that Medicare physicians would have sustained under the sustainable growth rate formula. The fine print also sets up a program that would require prior authorization (PA) for certain advanced imaging services. Reimbursement would be contingent on following certain protocols, with payment penalties for those who have exceeded usage thresholds.

Why is this important to those of us in the health information technology (health IT) business? Because it will ultimately require additional use of electronic health records (EHRs) to accommodate the necessary changes in standards as well as handle data exchange. It is also a harbinger of electronic prior authorization (ePA) for other procedures and devices. 

How it would work. In the short term, the law calls for identifying appropriate use criteria (AUCs)—kissing cousins to guidelines, we reckon--for diagnostic imaging, either developed or endorsed by medical specialty societies. Most likely, a federal advisory committee will be set up to recommend which AUCs to use. The AUCs must be identified by November 15, 2015 through rulemaking. Although they are not named, we’re guessing that the drafters of the legislation had magnetic resonance imaging and computed tomography and positron emission tomography scans in mind as “certain advanced imaging procedures.”

Then, in consultation with stakeholders, the government will identify clinical decision support (CDS) mechanisms that physicians and other will need to consult when ordering advanced imaging services for Medicare patients. The mechanisms may be part of a certified EHR and at least one must be free of charge. At a high level, the CDS mechanism — whether embedded in an EHR or not — must handle the mechanics of showing the AUCs were checked beforehand and documenting the encounter. Then, beginning January 1, 2017, payment will only be made if the claim shows that the ordering professional consulted with a qualified CDS mechanism; the ordered service adheres to the applicable AUC(s) and it contains the national provider identifier of the ordering professional.This may be the first time that Medicare would require providers to use such point- of-care, evidence-based ordering for exams or procedures, according to the American College of Radiology.

Also beginning in 2017 and in consultation with stakeholders, the Centers for Medicare and Medicaid Services (CMS) will identify “ordering professionals” who are not adhering to a threshold of applicable AUC(s), based on two years of data. These outlier physicians will be subject to PA for applicable imaging services in 2020.  What that means has yet to be defined, which likely will be in regulations down the road. The legislation provides CMS with $5 million in each of 2019, 2020, and 2021 to carry out the PA program.

Impacts. Now we get to the impacts. Like just about all regulatory requirements these days, the timeframes are tight. There’s not much time to officially get stakeholders together, for regulations to be promulgated, for vendors to build to them, for changes in health information exchanges to be made and for physicians to learn how to make this part of their work flow. Even if the dates are pushed back (which happens with regularity for most programs), a couple of years is not a lot of time to get everything done that needs doing.

Given the lead time required to pass legislation, promulgate regulations and create technical guidelines, vendors may really have to scramble once the certification criteria are established. It must be recognized that this will be hard work for vendors to absorb on top of all the other regulatory requirements, including stage 3 meaningful use. (For more details about how stage 3 is shaping up, see the article in this issue of HIT Perspectives.)

PA for procedures and devices currently is a paper/phone/fax-based process that is tedious and time consuming, and is ripe for automation. To accommodate the program spelled out in the law, changes may be needed to the ASC X12 278 standard. ASC X12 278 is designed and used for PA but it is not widely adopted by providers or payers. Given our experience with PA for medications, an ePA standard for procedures and devices is not beyond the realm of possibility. However it’s implemented, this legislation plants the seeds to make broader use of ePA a requirement across the board in the coming years.

To our way of thinking, if PA for high-cost imaging is on the horizon, can its use for other procedures and devices be too far behind, especially once the health IT infrastructure and standards are in place? Point-of-Care Partners is closely monitoring what sounds like a complex program to get off the ground. We will be keeping tabs on the many moving parts, which stakeholders end up in the drivers’ seat and which imaging procedures end up on the firing line.  Stay tuned because more ePA is coming your way.

Edited by Maurice Nagle
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