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The Protecting Access to Medicare Act

PAMA and MACRA – A Surprising Twist

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In the recent proposed rule for year two of The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Centers for Medicare and Medicaid Services (CMS) have introduced a surprising twist – linking the Protecting Access to Medicare Act (PAMA) to MACRA.

Tucked away on page 178 of the proposed rule is a new improvement activity linked to the Advancing Care Performance Category. This improvement activity allows organizations who have implemented a qualified Clinical Decision Support Mechanism (qCDSM) to receive credit in this category:

A MIPS eligible clinician would attest that they are consulting specified applicable appropriate use criteria (AUC) through a qualified clinical decision support mechanism for all advanced diagnostic imaging services ordered. This activity is for clinicians that are early adopters of the Medicare AUC program (e.g., 2018 performance year) and for clinicians that begin the program in future years as will be required by CFR §414.94 (authorized by the Protecting Access to Medicare Act of 2014). Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.

This development provides some tantalizing useful and important insight into the PAMA regulatory process:

  1. Providers must attest to consulting the qCDSM across all advanced imaging. We recognize that CMS has yet to publish the anticipated 3rd MPFS proposed rule; however this should clear up any mystery about limiting consultations to just the 8 Priority Clinical Areas (PCA). NDSC’s interpretation has always been that all advanced imaging orders require a consultation of applicable AUC, not just the PCAs.
  2. Our interpretation is that the timing for PAMA will now align with the first MACRA payment adjustment. CMS is rewarding providers who have or are currently adopting AUC based on CMS’ guidance that starting Jan 1 2018, claims for Medicare Part B advanced imaging services require evidence of a qCDSM consultation.

In short, the country’s largest payer now requires consultation with a qCDSM across all advanced imaging services. This is certain to have implications for traditional utilization management approaches that rely on prior authorization through third parties.

Useful Links: MACRA Proposed Rule Fact Sheet

Walking Paper

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A Walking OrderImaging 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.

Beyond Compliance
Prescription Pad - Beyond Compliance

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.

Email Decision Support NumberThe 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.

 

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