In a report delivered June 15 to the U.S. Congress, the Medicare Payment Advisory Commission (MedPAC) urged Medicare to require clinicians who order more imaging studies than their peers to obtain prior authorization for advanced imaging.
MedPAC's recommendation would give the U.S. Centers for Medicare and Medicaid Services (CMS) a tool for cracking down on imaging overuse, requiring high-volume physicians to go through a preauthorization process, while practitioners with a low rate of use would only be subject to prior notification, according to the panel's report.
The panel also urged CMS to lower payments for successive imaging studies performed during the same imaging session, and it outlined various scenarios for addressing the sustainable growth rate (SGR) formula problem that has dogged the country for years -- and which is scheduled to reduce physician fee schedule payments by 30% in 2012 if not resolved.
Physician investments in diagnostic testing equipment have contributed to rapid growth of advanced imaging services under the Medicare Physician Fee Schedule (MPFS), MedPAC wrote. But physician self-referral in and of itself is not the problem, the panel said: Physician self-referral of ancillary services leads to higher volume when combined with fee-for-service payment systems, which reward higher volume, and mispricing, which makes some services more profitable than others.
What is MedPAC's solution? Bundling payments for multiple services that are often furnished together, and reducing payment for ensuing services after the initial one. The commission also proposed establishing a prior notification and prior authorization program.
According to MedPAC, CMS could begin by comparing outlier physicians' use of imaging to evidence-based clinical guidelines and educating physicians about the appropriate use of imaging, encouraging providers to use clinical decision-support systems instead of participating in a prior notification program.
In a second stage, outlier physicians who order imaging inappropriately would be required to participate in a prior authorization program, in which CMS or a contractor would review and approve their requests to order imaging services before they are provided. Outlier physicians who order imaging appropriately would not be subject to prior authorization.
In response to the report, the Medical Imaging and Technology Alliance (MITA) called on Congress to reject MedPAC's recommendations to reduce reimbursement for advanced imaging.
"[MedPAC] continues to recommend dramatic reimbursement cuts as well as a prior authorization program that would result in reducing seniors' access to imaging services," said Dave Fisher, MITA's executive director.
