Imaging providers may see fewer requests for imaging services to senior citizens if the Medicare Payment Advisory Commission (MedPAC) has its way. The influential advisory group is urging that physicians who order too many MRIs, CT scans, nuclear medicine studies, and other imaging tests be required to obtain pre-approval from Medicare.
Preauthorization criteria would be based on clinical guidelines developed by specialty groups, literature reviews, and expert panels. In addition, the protocol could serve as a kind of "gold card" for physicians with low rates of unnecessary use, according to Ariel Winter, a senior analyst at MedPAC.
In its latest report, sent to Congress last Wednesday, MedPAC attributes soaring Medicare expenditures in part to inappropriate ordering of tests by physicians who are increasingly buying their own high-tech equipment and can pocket the profits when they can perform diagnostic tests in their own offices.
"There's some bad behavior going on out there, with physicians buying imaging equipment and generating unnecessary services," states Robert Berenson, MedPAC vice chairman, "It seems prudent to target high utilizers for authorization." By MedPAC’s calculations, the top 10% of physicians account for more than 50% of advanced imaging use, and a significant share of these top 10% self-refer, Winter notes.
Not surprisingly, the recommendation is sparking a battle with physicians and patient groups who argue that Medicare beneficiaries might suffer significant delays in treatment. Industry pundits say outpatient imaging centers will probably feel the impact of the recommendations first, as they often have a disproportionate share of procedures coming from the very physicians targeted in the MedPAC recommendation. Meanwhile, hospitals have some benefit associated with the broader mix of inpatients, outpatients, and patients from the emergency department, and hospital-based radiology departments usually see patients referred by a broader cross section of referring physicians.
- MedPAC Recommends Prior Authorization For Advanced Imaging
- Imaging Coalition Rejects MedPAC Recommendation
- To Read or Not to Read, blog post by Curtis Kauffman-Pickelle