Docs Brace for Medicare ‘Appropriate’ Imaging Rule | Medpage Today

Advocates for Medicare for All and similar systems regularly create the impression that such systems will not come between you and your doctor; implying unfettered access to any and all care.

The fact is that no system can operate that way if the goal is both quality care and affordable care.

Advocates (and health care professionals) regularly complain about insurance company efforts to manage care, usually incorrectly aligning that with profits.

Some oversight, some looking over the shoulder, some second guessing is good for health care, both cost and quality. The question is who should do it and how.

One thing is certain, under a universal system paid for with taxes and operating under a national budget, somebody will be looking at the care being provided and determining what will and will not be paid for. How can it be otherwise?

As the medical community braces for implementation of the Protecting Access to Medicare Act (PAMA) by the Jan. 1, 2020 deadline, some wonder if it’s even feasible or if another program delay is on the horizon. The policy, aimed at reducing unnecessary testing, mandates that all advanced diagnostic imaging orders go through an algorithm that provides key confirmation codes required when Medicare is billed later on for the service.

Dubbed a “clinical decision support mechanism” (CDSM), this software processes each CT, MRI, nuclear medicine, and PET order before spitting out its verdict to the ordering professional: “appropriate,” “maybe appropriate,” or “rarely appropriate,” according to a certain set of appropriate use criteria (AUC). Essentially, the CDSM confirmation code provides proof that the ordering physician consulted AUC. Eventually, Medicare will not pay claims for advanced imaging without these codes.

The program has been delayed several times, and the 2020 deadline equates to a “soft launch,” as improper imaging claims won’t be rejected until the following year, with no firm deadline for additional penalties beyond that. Still, many physician organizations have raised concerns about the policy.

Source: Docs Brace for Medicare ‘Appropriate’ Imaging Rule | Medpage Today

One comment

  1. Have already been caught up in suche a debacle when an MRI and CT scans were set up a few days earlier than the three month suggested limit. An administrative genius questioned me on the need to have the series of tests so early. Mind you we are talking about a few days early. Th hospital set it up and the had to ultimately accept a reduced settlement. I can see a need to monitor and look for abusive use or billing of services considered outside the parameters. Like over prescription of opioids.


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