New Medicare Imaging Appropriateness Criteria
Demonstration Project
Frequently Asked Questions
What is the Medicare Appropriateness Criteria Demonstration
Project?
Does the ACC support the demonstration project?
Will my practice need to participate?
Will the demonstration project focus on all imaging modalities?
Will participating practices receive reimbursement to cover
the administrative cost of participation?
How will appropriateness criteria be selected for the demonstration?
How will data be collected under the demonstration?
Could CMS require prior authorization under the demonstration?
What is the Medicare Appropriateness
Criteria Demonstration Project?
The new Medicare law includes the establishment of a voluntary two-year
Medicare demonstration project to assess the appropriate use of imaging
services by January 1, 2010. The demonstration will collect data relating
to physician compliance with appropriateness criteria in order to determine
the appropriateness of advanced diagnostic imaging services furnished
to Medicare beneficiaries.
Does the ACC support the demonstration project?
The ACC urged Congress to establish a Medicare demonstration project
of appropriateness criteria use to help address important questions
related to the growth in imaging utilization that will ultimately lead
to better policy decisions.
Will my practice need to participate?
No, practices are not required to participate. Physicians who are interested
in participating in the demonstration will be required to submit an
application to the Secretary of Health and Human Services in a manner
to be determined by the Secretary. The Secretary will select the physicians
to participate in the demonstration based on the following criteria:
(i) represent a wide range of geographic areas, demographic characteristics
(e.g., urban, rural, and suburban), and practice settings; and (ii)
have the capability to submit data to the Secretary in an electronic
format in accordance with standards determined by the Secretary.
Will the demonstration project focus on all imaging
modalities?
The demonstration project is focused on advanced diagnostic imaging
services, which is defined to include MRI, CT, nuclear medicine/PET.
The Secretary of Health and Human Services (HHS) has the authority to
focus the demonstration project on services that account for a large
amount of Medicare expenditures, services that have recently experienced
a high rate of growth, or services for which appropriateness criteria
exists.
Will participating practices receive reimbursement
to cover the administrative cost of participation?
The Secretary will reimburse physicians for the reasonable administrative
costs incurred due to participation in the demonstration and provide
reasonable incentives to encourage physicians to participate in the
demonstration.
How will appropriateness criteria be selected
for the demonstration?
The Secretary of Health and Human Services is required to consult with
medical specialty societies and other stakeholders in crafting such
criteria. The criteria selected would be required to be: (i) developed
or endorsed by a medical specialty society; and (ii) developed in adherence
to appropriateness principles developed by a consensus organization,
such as the AQA alliance.
How will data be collected under the demonstration?
The Secretary is required to use each of the following two models for
collecting data regarding physician compliance with appropriateness
criteria in carrying out the demonstration project.
The point of service model uses an electronic or paper intake form
that: (i) contains a certification by the physician furnishing the imaging
service that the data on the intake form was confirmed with the Medicare
beneficiary before the service was furnished; (ii) contains standardized
data elements for diagnosis, service ordered, service furnished, and
such other information determined by the Secretary, in consultation
with medical specialty societies and other stakeholders, to be relevant
to evaluating the effectiveness of the use of appropriateness criteria;
(iii) is accessible to physicians participating in the demonstration
project in a format that allows for the electronic submission of the
form; and (iv) provides feedback reports (discussed below).
The point of order model is a model that: (i) uses a computerized order-entry
system that requires the transmittal of relevant supporting information
at the time of referral for advanced diagnostic imaging services and
provides automated decision-support feedback to the referring physician
regarding the appropriateness of furnishing such imaging services; and
(ii) provides for feedback reports.
Could CMS require prior authorization under the
demonstration?
The Secretary is not permitted to use prior authorization as a model
for collecting data regarding physician compliance with appropriateness
criteria or under any model used to collect data under the demonstration
project.
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