Thursday, February 22, 2024

Nerd Note: CMS DeepSixes the Advanced Imaging "Appropriate Use Criteria" that Congress Gave It

Header:  The Lab Industry remembers PAMA 2014 for lab pricing law, but it also created Appropriate Use Criteria (AUC) for Imaging.  It's fallen down, as did a Radiation Oncology payment model.


PAMA #1 - Lab Price

PAMA, the Protecting Access to Medicare Act, in the lab industry is shorthand for a major new lab test repricing law, based on median community pricing of lab tests.  PAMA has been on hold and in limbo from 2020 to at least 2025.

PAMA #2, #3 - RVU Rules and AUC Project

Two other initiatives from PAMA were a section that gave CMS much more authority to set and revise RVU values, and a section that created mandatory "Appropriate Use Criteria" for advanced imaging (e.g. MRI).

The Advanced Imaging AUC Project

The AUC proceded in fits and starts and has finally been put on hold indefinitely, as per a recent notice to contractors from CMS.   More details could be found by perusing 8 years of Federal Register annual rulemakings on the topic.

Tie In to Genomics

I thought the AUC was worth watching becaise" if you could apply required AUC to orders for $600 MRI tests why not also apply required AUC rules to $3000 genomic tests.   


BTW - RO Model Also Deep Six'ed

Speaking of radiology, another issue was radiotherapy, where CMS proposed an unpopular Radiation Oncology bundled price model that was "modality agnostic."  This was extremely unpopular in the clinical community and was even delayed sometimes by an act of Congress.   See an extensive, 6-page letter on perceived severe problems with RO MODEL, written by numerous stakeholders to CMS in 2021.

See a 2021 article on RO MODEL by Milliman here.

In 2022, the RO MODEL was delayed or suspended to cancel a prior go live date in 2023, and stop or delay out to a future date "to be determined." 

See ASTRO,   

See also Fierce Healthcare on the same topic,

AI Corner

Perplexity discusses the 7-page ASTRO and multi stakeholder complaint to CMS, here.