MedPAC Recommends Prior Authorization For Advanced Imaging

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imageThe Medicare Payment Advisory Commission (MedPAC) on April 7 passed a recommendation that Medicare require clinicians who order more imaging studies than their peers obtain prior authorization for advanced imaging.

MedPAC voted on the recommendation during a public meeting held in Washington, DC, with only one of 16 voting members of the Congressional advisory panel objecting to its passage. In a presentation to meeting attendees, MedPAC Senior Analyst Ariel Winter said the recommendation would yield the U.S. Centers For Medicare and Medicaid Services (CMS) a tool for cracking down on imaging overuse by requiring high-volume physicians to go through a preauthorization process. Practitioners with a low rate of use would only be subject to prior notification, Winter explained, adding that the top 10% of physicians account for more than 50% of advanced imaging use, and a significant share of these top 10% self-refer. Preauthorization criteria would be based on clinical guidelines developed by specialty groups, literature reviews, and expert panels, and the protocol could serve as a kind of "gold card" for physicians with low rates of unnecessary use, according to Winter.

MedPAC's data demonstrate a slowdown in the rate of imaging growth from 2008 to 2009. The volume of all imaging (units and intensity) rose by 2% per Medicare fee-for-service beneficiary during that year; the volume of advanced imaging, by 0.1% per beneficiary. Industry data for the same time frame shows a 7.1% decline in the volume of all imaging and a 0.1% decline in the volume of advanced imaging. However, Winter pointed to "issues with industry's method" of calculating the data, purporting that cumulative growth in imaging volume in the physician fee schedule between 2000 and 2009 was 85%, thereby raising concern about both appropriate use and radiation exposure for patients.

Industry reaction to MedPAC's recommendation has not been entirely positive. In a statement issued following the meeting, the Medical Imaging and Technology Alliance (MITA) claims MedPAC “continues to rely on out-of-date data to reach inaccurate conclusions regarding the use of life-saving advanced medical imaging services”. The statement goes on to note that while MedPAC, during the presentation,“ finally admitted that imaging utilization is flat”, it “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."

A second recommendation approved by the panel during the meeting says CMS should lower payments for successive imaging studies performed during the same imaging session. The public session and ensuing vote follow a February meeting during which MedPAC commissioners discussed draft recommendations to improve payment accuracy and the appropriate use of ancillary services, including imaging and other diagnostic tests.