CMS Finalizes Pause to Imaging Appropriate Use Criteria Program

The Centers for Medicare and Medicaid Services (CMS) in the 2024 Medicare Physician Fee Schedule (MPFS) final rule finalized its proposal to pause the implementation of the Protecting Access to Medicare Act (PAMA) imaging appropriate use criteria (AUC) program. CMS continues to have concerns with the real-time claims processing aspect of the act. The final rule emphasizes the agency’s support of the PAMA AUC program, but says more time is needed to reevaluate the program to ensure that imaging claims are not inappropriately denied.

The American College of Radiology® (ACR®) recognizes the significant issues CMS faces with the real-time claims processing aspect of the AUC program and the potential impact on members if claims are denied inappropriately. The College is working with Congress to streamline and modernize the PAMA AUC program, including the removal of the claims-based reporting requirement, to allow the program to move forward and ensure Medicare patients receive the right imaging tests at the right time. The rule states that a fully implemented program could result in potential savings to the Medicare program of up to $700 million annually. An independent analysis by The Moran Company estimated the AUC program savings at a smaller, but still significant $2 billion over 10 years.

Despite the implementation barriers necessitating the reevaluation of the program, CMS recognizes the value of AUC to improve utilization patterns for Medicare beneficiaries. The rule states, “We want to acknowledge and emphasize the value of clinical decision support to bolster efforts to improve the quality, safety, efficiency and effectiveness of health care. We welcome and encourage the continued voluntary use of AUC and/or clinical decision support tools in a style and manner that most effectively and efficiently fits the needs and workflow of the clinician user. Across many specialties and services, not just advanced diagnostic imaging, clinical decision support predates the enactment of the PAMA and, given its utility when accessed and used appropriately, we expect it to continue being used to streamline and enhance decision making in clinical practice and improve quality of care.”

CMS states multiple times within the final rule that they will “continue efforts to identify a workable implementation approach and will propose to adopt any such approach through subsequent rulemaking, including implementing any amendments Congress might make.”

The PAMA imaging AUC program, passed by Congress and signed into law in 2014, requires ordering providers to consult AUC developed by provider-led entities through a clinical decision support mechanism when ordering advanced diagnostic imaging, including CT, MR, PET and nuclear medicine, for Medicare Part B patients. It was designed as an alternative to prior authorization to decrease inappropriate imaging. If the program were to be fully implemented as currently written in law, payment for imaging services that do not contain the appropriate AUC consultation information on applicable claims would be denied. The program has been operating in an “educational and operations testing period” without payment penalties in place since Jan. 1, 2020. The decision to pause the program includes pausing the ongoing educational and operations testing period, effective January 1, 2024.

For more information, contact Katie Keysor, ACR Senior Director, Economic Policy.