Imaging orders flow to furnishing sites in a variety of ways. Too often, these orders are “sent” via the patient, who leaves the caregivers office with a piece of paper. We get a lot of questions about how to manage walking paper, including orders via email and the trusty fax machine, with consideration of the new PAMA requirements. Here is our solution.
A PAMA Refresher
The central requirement of the Protecting Access to Medicare Act of 2014 requires that caregivers who order advanced imaging tests provide evidence of consultation of a Clinical Decision Support Mechanism (qCDSM). The qCDSM must leverage Appropriate Use Criteria (AUC) from a qualified Provider Led Entity (qPLE).
Consultation with AUC when placing imaging orders is proven to reduce inappropriate utilization, and the consultation requirements for Medicare Part B advanced imaging services introduced by CMS replace the need for prior authorization of these services.
Countless paper orders are generated in the ambulatory setting when ordering or furnishing advanced imaging. The caregiver is required by law to consult AUC, and the furnishing provider must submit evidence of said consultation with the claim to receive payment.
Access is critical
The answer to most of the questions lies with access. As the law does not provide for a “proxy” consultation, widespread access to a CDSM for caregivers in the ambulatory setting is central to compliance with the program. Furnishing providers are rightfully concerned about generating a payable claim.
For caregivers in the ambulatory setting that frequently order advanced imaging, EMR integration makes access to the CDSM easy, routine and automatic. Integration ensures that the order will always contain the required evidence of consultation, whether sent electronically or printed. The paper simply needs to contain the unique transaction identifier called a Decision Support Number (DSN). This DSN links the order to all the needed claims data.
To ensure widespread access in the ambulatory setting, where services are ordered but not furnished, NDSC now offers a complimentary version of our CDSM known as ACR Select™ Basic. ACR Select Basic is available within numerous ambulatory EMRs in widespread market use. This ensures that caregivers are always able to consult a CDSM when needed.
For Caregivers who infrequently order advanced imaging, or do not have integrated EMR access, we offer a complimentary web site that can generate evidence of a consultation for compliance with PAMA.
Practically speaking, when a furnishing site receives a fax or a piece of paper with a DSN, they can easily access the data associated with a consultation and guarantee that the claim is payable.
We recommend to furnishing sites to adapt their business process and policy associated with furnishing Medicare Part B advanced imaging orders to include awareness and education regarding the availability of this free resource to the ordering provider in the event an order is received without the required evidence.
When paper walks, determining why the imaging exam was selected often requires phone calls, exchange of notes, and a lot of frustration. Often, when the patient arrives, they don’t know why or where imaging is needed.
Then there’s the matter of payment. Once the ambulatory imaging provider does determine why the exam is needed, a similar process of phone calls and faxes starts with the payer. This is not generally a doctor to doctor exchange. Doctors are busy enough, so administrative staff fill in.
As our population ages, the range and specificity of medical testing options are only increasing. Insurance companies continue to “guide” care and selecting the right tests to ensure the correct outcome can be a challenge. It’s not getting any easier for either side of the imaging chain to navigate this new landscape. Survival is no longer about just doing “more”. Instead, it is about doing more of the right thing and a renewed focus on the patient.
The solution starts with the ordering provider asking a clear, clinical question to answer through imaging that the furnishing imaging provider can understand. When linked to a DSN, that indication can flow from order all the way through billing.
The communication of clear, structured data across sites of care, whether on a piece of paper or embedded within an electronic message delivered through our CareSelect™ solution unleashes a slew of possibilities.
Medicare Part B services are effectively authorized by qCDSM consultation. Across every use case, paper is reduced, more appropriate services are ordered, and furnishing sites receive better information.
CareSelect Imaging delivers multiple AUC sets to provide not only the most appropriate test for PAMA compliance, but to incorporate payer criteria and enable providers to leverage our technology to reduce the administrative burden of the prior authorization process through automation.
Interested in Learning More About PAMA?
Join our PAMA webinar featuring Erin Lane from the Advisory Board Company on March 9th.