CMS May Require Some Doctors to Get Pre-Authorization for Imaging

High utilizers of advanced medical imaging beware: the Medicare Payment Advisory Commission (MedPAC) just voted 15-1 this month to recommend to Congress that the top tier of referrers of advanced medical imaging should get prior authorization first.

The imaging studies include MRI, CT, PET scans, and nuclear medicine, with the stated intent of ensuring that outliers are appropriately using imaging.

The idea is that the change takes aim at high referrers who do so inappropriately. CMS would divide providers into two categories: those who order substantially more studies than their peers, and those who don't. For the latter category, no authorization requirements will be needed when ordering imaging studies. For the high utilizers, those who are found by CMS to have a low rate of inappropriate use would only be subject to prior notification for these advanced imaging studies, while the providers deemed high referrers for inappropriate imaging use would be required to obtain prior authorization from CMS.

Ariel Winter, a MedPAC senior analyst noted that 10 percent of physicians ordered 50 percent of the volume of advanced studies. And a “significant number” of the 10 percent were self-referring physicians. The recommendation for prior authorization does not focus on just self-referrers, but rather any high utilizer in the top bracket.

While implementing the recommendation, CMS would aim to minimize wait time for patients as well as the administrative burden for physicians, Winter said.

He estimated that CMS would save up to $50 million the first year, and up to $1 billion over five years by requiring authorization from this set. In addition to the money saved, patient exposure to unnecessary radiation would be reduced.

This was one of four recommendations passed at the April 7 MedPAC meeting in Washington, DC. MedPAC advises Congress on Medicare and Medicaid (CMS) issues. The other recommendations, passed unanimously, include:

• accelerating and expanding efforts to package discrete services in the Physician Fee Schedule into larger units for payment;

• applying a multiple procedure payment reduction to the professional component of diagnostic imaging services provided by the same practitioner in the same session;

• reducing the physician work component of imaging and other diagnostic tests ordered and performed by the same practitioner.

The recommendations were made to improve payment accuracy and appropriate use of ancillary services.

In introducing the recommendations, Winter cited CMS data that he acknowledged was different than industry data. For example, he noted industry figures that the volume of all imaging services declined 7.1 percent from 2008 to 2009, while advanced imaging volume decreased by 0.1 percent. Winter said that according to CMS data, imaging services per fee-for-service beneficiary increased by 2 percent during the same time period, while the volume of advanced imaging services increased by 0.1 percent for that fee-for-service beneficiary. 

Winter noted a broader trend in imaging: From 2000 to 2009, the cumulative growth from imaging was faster than all other physician service categories, other than testing. He stated that cumulatively, imaging rose 85 percent while other physician services rose 47 percent.

Industry trade group the Medical Imaging and Technology Alliance (MITA) was not pleased with the CMS data, nor with the recommendations. In a public statement, MITA said:

“MedPAC continues to rely on out-of-date data to reach inaccurate conclusions regarding the use of life-saving advanced medical imaging services. Today, while MedPAC finally admitted that imaging utilization is flat, they still approved recommendations to further cut reimbursements to imaging procedures that have experienced significant cuts during the last five years and already face added cuts over the next few years.

“Medicare claims data shows that since 2006 payments for imaging procedures are down significantly and the utilization growth is flat. There are real-world consequences to again imposing reimbursement cuts on these procedures – new innovations don’t come to market, patients lose access to life-saving technologies and people lose their jobs as imaging equipment manufacturing is artificially slowed by short-sighted policy.”