Medicare’s push to link payment for advanced diagnostic imaging to appropriate use criteria and the Medicare Payment Advisory Commission’s (MedPAC) site-neutral payment recommendation topped the agenda at the American College of Cardiology’s (ACC) most recent legislative conference.
Because of a provision in the Protecting Access to Medicare Act, in 2017 Medicare claims for advanced diagnostic imaging services will be paid only if the claims include documentation that the physicians ordering the tests consulted appropriate use criteria (AUC). The mandate will apply to services performed in physicians’ offices and the hospital outpatient setting, excluding emergency services.
Although the obligation to document consultation of AUC falls on the referring physician, payment is at risk only for the performing physician. The result could be a shift in referral patterns rather than more appropriate use, reported Prem Soman, MD, PhD, of the University of Pittsburgh Medical Center, and Rebecca Kelly, senior director for regulatory affairs in the advocacy division at the ACC. They published their synopsis in the January issue of the Journal of the American College of Cardiology: Cardiovascular Imaging.
“The potential consequences of this AUC mandate for the cardiac imaging community may be unpredictable,” they wrote. Several questions remain: How will implementation of the mandate affect workflow for referring and performing physicians? How will information flow from referring physicians to imaging laboratories? Who should be responsible for the implementation in a referral-based environment?
Meanwhile, cardiology professionals have to worry about a funding cut if MedPAC’s 2014 recommendation that Congress enact “site-neutral” policies is implemented.
“Site-neutral” policies would equalize Medicare Hospital Outpatient Prospective Payment System (HOOPS) and Medicare Physician Fee Schedule (PFS) payment rates for 66 outpatient service groupings. Such a switch would result in payment amounts decreasing and have substantial impact for cardiovascular medicine, Soman and Kelly wrote.
“It is important to note that the effect of implementing site neutrality will not be redistribution of payments within or between the HOPPS and the PFS, but rather a net reduction in payments for cardiovascular imaging services,” they write.
The good news: Legislation would be required to implement MedPAC’s recommendation, and no such legislation has been introduced yet. However, it’s possible that Congress will look to a site-neutral payment policy as an offset for the cost of repealing or patching the sustainable growth rate before the temporary patch expires at the end of March 2015, and even further into the future, Soman and Kelly wrote.