What You Need to Know: AUC Mandate and Content Licensing
In March 2014, Congress passed the Protecting Access to Medicare Act of 2014 (H.R. 4302) which includes a provision requiring ordering professionals to consult with appropriate use criteria (AUC) through a clinical decision support (CDS) mechanism for all Medicare patients receiving advanced imaging (cardiac nuclear, CT, MR).
Under the law, only AUC developed by entities meeting the “provider-led entity” (PLE) standards as defined by regulation can be used under the program. On June 15, the ACC was informed that it meets requirements to be a qualified PLE to develop and modify AUC under the Medicare AUC program for advanced diagnostic imaging. As a result, the national AUC developed by the College will be an accepted standard for cardiologists and others when submitting to Medicare for the review of cardiac imaging.
Next up, the Centers for Medicare and Medicaid Services (CMS) will establish regulations in the 2017 and 2018 Physician Fee Schedules addressing additional parts of the program, such as the requirements for approved CDS vendors and the identification of “priority clinical areas,” where CMS will focus initial measurement of outliers in this program. An anticipated launch date of Jan. 1, 2018 will allow ordering professionals to begin consulting with a qualified CDS system and furnish certification or documentation of the consultation to the furnishing professional. CMS will also begin identification of “no more than five percent of the total number of ordering professionals” who are outliers.
At a later date, CMS shall apply prior authorization for applicable advanced imaging services ordered by clinicians identified as outliers using data collected from the program. The prior authorization start date is set as Jan. 1, 2020 in the legislation; however, CMS may adjust this date through the regulatory process given the implementation delay.
The ACC will be listed as a qualified PLE on the CMS website by June 30, 2016, and will be recognized as a qualified PLE for a five-year period, ending in June 2021. In order to maintain PLE status, the College will re-apply to CMS by Jan. 1, 2021.
Since 2010, the ACC has offered FOCUS to help its membership and imaging labs benchmark their AUC performance for quality improvement and to meet lab accreditation AUC requirements. The evolution of AUC review from periodic lab assessment for accreditation to ongoing use of clinical decision support requires wide availability of AUC algorithms. To this end, the College is engaging with several technology partners and standards development organizations to test and license the official ACC AUC algorithms for cardiovascular imaging.
Licensing the AUC algorithms to a wide set of CDS vendors will provide members and their institutions choices in how to meet this pending mandate. All licensees of the ACC AUC algorithms will be using a standardized set of ACC content to ensure consistency in how testing appropriateness is determined. These vendor partners are expected to integrate the ACC cardiology content with AUC content from other specialties, including ACR Select radiology content, to offer a comprehensive solution for meeting this mandate. These solutions will vary from fully integrated electronic health record solutions to web-based and app-based technologies to allow practices flexibility in how they meet the requirements of the mandate. It is expected that multiple CDS vendors will be qualified by CMS to submit AUC data required under the mandate including AUC score, decision support number, imaging procedure, and other related information.