Following ongoing Texas Medical Association advocacy, federal lawmakers are pushing for more information on Medicare’s beleaguered appropriate use criteria (AUC) program, which – despite its goal of cutting down on excessive imaging tests – requires physicians to jump through administratively burdensome hoops to reach that goal.
U.S. Reps. Rosa DeLauro (D-Connecticut), Kay Granger (R-Fort Worth), and Tim Ryan (D-Ohio) recently requested a report from the Centers for Medicare & Medicaid Services (CMS) on the implementation of AUC as part of a fiscal year 2022 omnibus spending bill.
Under AUC, physicians ordering advanced imaging tests would have to first consult Medicare’s criteria using an electronic portal, which evaluates whether a test meets Medicare’s definition of “appropriate use.” Eventually, under full implementation of the program, Medicare could potentially deny claims for physicians who don’t document that system check – and the agency could also label doctors test-ordering “outliers” and subject them to prior authorization.
TMA previously warned CMS about the “enormous process and cost burden” AUC would impose on physician practices. And the lawmakers’ report request dovetails with TMA’s ongoing advocacy to delay implementation of AUC. TMA recently sent comments to CMS in response to the proposed 2022 Medicare Physician Fee Schedule, in which CMS proposed to delay enforcement of the AUC program until either the beginning of 2023 or the beginning of the calendar year that follows the end of the pandemic, whichever is later.
TMA and 39 other professional medical societies sent letters to the three lawmakers lauding their efforts in pursuing the report on AUC.
“We are optimistic the report language will result in a long-overdue discussion that will lead to legislative repeal of or substantial revision to the law thereby affording physicians and other health care providers the flexibility to consult AUC in a form and manner that is practical, efficient, and meaningful to them and their practices,” TMA and the other signatories wrote.
Congress established the AUC program in 2014, when it passed the Protecting Access to Medicare Act, but CMS has since struggled to implement the program, according to TMA’s letter. Meanwhile, the program has grown obsolete as new Medicare payment and delivery models that hold physicians responsible for health care resource use – including the Merit-Based Incentive Payment System, accountable care organizations, and alternative payment models – have evolved.
TMA strongly supported CMS’ proposal to delay AUC and applauded the agency for recognizing the burdens the program creates for physicians, especially during the ongoing pandemic when many physician practices and hospital systems are experiencing staffing shortages.
“While TMA acknowledges the importance of evidence-driven ordering, we maintain operational concerns with the AUC program that must be addressed before its enforcement,” the association wrote in the Sept. 13 comment letter. “Further, the COVID-19 [pandemic] greatly limits physician practices’ ability to prepare or to participate in an educational campaign and operations testing period.”
Emma Freer
Associate Editor
(512) 370-1383