By Nathan Baugh
On July 13th , the Centers for Medicare and Medicaid Services (CMS) proposed to delay the “penalty phase” of the Appropriate Use Criteria (AUC) program to at least January 1, 2023. This marks the fourth time that CMS has delayed the penalty phase of the AUC program which was supposed to begin in 2017.
The delays have largely been related to complexity of reporting AUC information on Medicare claims, which has clearly been more challenging to operationalize than CMS anticipated. It is fair to say that everyone, including CMS, is frustrated by these delays, but they have been necessary. The program is simply not ready to begin a “penalty” phase without denying a significant volume of imaging claims and thankfully CMS is not rushing to meet a deadline at the expense of the imaging community.
AHRA has been working with CMS for years now to try and move this program forward in a way that creates as little disruption as possible for the imaging field. We are glad to see that in this proposed rule, CMS has adopted a few of our suggestions on how to address some of the ongoing AUC implementation challenges.
For instance, in 2020, AHRA expressed concerns regarding the Appropriate Use Criteria program to CMS in a letter noting that “the most significant concern AHRA has with the current AUC policy is the fact that the language surrounding who the ordering professional may delegate the [AUC] consultation to is too vague and open for interpretation.”
In this rule, CMS proposes a clarification of AUC program scope in which they note that “furnishing professionals may not consult AUC on behalf of or in place of the ordering professional.”
This clarification is important because previous rulemaking from CMS on this issue had left the door open ~ ever so slightly ~ for furnishing professionals to be able to perform the consultation of AUC for the ordering professionals. Besides defeating the educational goals of the program (i.e. to support clinical decision making surrounding advanced imaging), AHRA feared that ordering professionals might try to push the responsibility of AUC consultation on the furnishing provider.
Furthermore, in that same 2020 letter to CMS, AHRA asked that “CMS lay out, publicly, exactly what challenges still exist for the entire healthcare community to see.”
Until this proposed rule was released, there was no official summation of the claims processing issues causing the program to be delayed. However, in this proposal, CMS has now identified 9 “challenging or impracticable” areas where they seek feedback from stakeholders on operational solutions. We are happy to see CMS publicly list the operational challenges in this proposed rule as AHRA believed that this was an important next step to take. Imaging stakeholders can now use this official assessment of the claims processing hurdles to work with CMS and identify solutions that are as minimally burdensome as possible.
While this rule does address some of the lingering issues with the AUC program and gets the policy close to being ready for implementation, the rule still leaves the door open for additional delays in the future. If the issues CMS has identified in this proposed rule are satisfactorily solved by the time the final rule comes out in November, the penalty phase could begin in 2023. However, if these claims processing issues prove insurmountable, then we could easily see a fifth delay of the penalty phase.
You can get more information at the AHRA annual conference. Melody Mulaik and Sheila M. Sferrella will present Regulatory Update 2021 and Nathan Baugh will present Washington Update. Both of these talks will provide much more detail about the proposed rules, the work the AHRA Regulatory Committee has done with CMS and much more.