Not surprisingly, this year’s rulemaking cycle proposes to delay the implementation of the Protecting Access to Medicare Act (PAMA) to January of 2019. The additional time will allow healthcare providers to implement the claims reporting requirements as detailed in the proposed rule and for CMS to implement the required changes in the claims process.
The team at NDSC is developing our summary of the rule and will be updating our customers over the next several weeks. What’s important about this rulemaking cycle is not what’s in the rule, but what is not.
What’s still missing is how CMS intends to flag ordering providers as outliers. Providers need to be aware that both adherence to the Appropriate Use Criteria (AUC) within the Priority Clinical Areas and the applicability of the AUC to their scope of practice are opportunities for CMS to flag providers as outliers. Adherence to and applicability of the AUC are both in scope for outlier calculation.
CMS reiterated a comprehensive consultation requirement, requiring evidence of consultation to be generated for every advanced diagnostic imaging service paid for under Medicare Part B. This comprehensive consultation requirement translates to comprehensive measurement. qCDSMs must report not only on adherence to AUC, but also applicability of the AUC to the service.
Healthcare organizations and caregivers must position themselves not only to comply, but implement a solution that assures that their caregivers are best positioned to avoid the additional burden of prior authorization implied by the statute.
The Upshot
If an organization implements a CDSM that does not deliver AUC to cover the providers’ full scope of practice, many consultations will not yield applicable AUC. This increases the risk that the providers will be subject to the additional burden of prior authorization for Medicare beneficiaries. Again, adherence to and applicability of the AUC are both in scope for this calculation.
The reporting requirements outlined in rulemaking are a subset of the data that the qCDSM must record. Combined with the requirement that qCDSM must store data for 6 years, we can expect that the data recorded in the mechanism to be subject to audit.
While NDSC is pleased to be “qualified”, this qualification simply indicates that our technology meets a minimum standard, including AUC coverage of PCAs. This minimum standard does not consider the scope of practice for a provider. When considering a strategy for compliance, ensuring that AUC cover the full scope of practice is a critical decision point for caregivers when implementing a qCDSM.
We also believe that it is critical for caregivers to have easy access to a qCDSM. The CareSelect™ platform is the only fully qualified mechanism that offers no-fee access. This ensures that regardless of where the evidence of consultation needs to be created, or where a claim needs submission, caregivers can always access the required information to comply.
As an organization, NDSC is qualified. We’ve integrated our qCDSM into every major EMR platform on the market, and have the most comprehensive AUC libraries at our disposal. Healthcare providers at over 300 healthcare organizations, covering over 2500 facilities trust our system to guide their imaging choices over 3 million times a month. CareSelect™ is a fully qualified mechanism, backed by a fully qualified organization.
For the 2018 MIPS performance period, CMS added a new improvement activity that MIPS eligible clinicians could choose if they attest they’re using AUC through a qualified clinical decision support mechanism for all advanced diagnostic imaging services ordered.
Additional coverage from the ACR: American College of Radiology’s Proposed Rule Summary
