Updated Medicare Appropriate Use Criteria (AUC) will go into effect Jan. 1, 2020. On that date, providers must document that AUC was consulted when ordering outpatient advanced imaging (CT scans, MRIs, PET, or nuclear medicine) for Medicare fee-for-service beneficiaries. For patient access, the big question is: Is this Medicare’s first step toward requiring authorizations for radiology services? “Though it is being stated as a ‘review’ and suggestion system to better utilize healthcare, I do believe this is step one of Medicare instituting authorizations for high-end radiology procedures,” predicts Craig Pergrem, senior director of preservice and onsite access at Winston-Salem, NC-based Novant Health.
Medicare has seen the success that managed care companies have experienced with similar requirements on Medicare replacement plans. “They are smart to follow suit for cost savings,” Pergrem says. “With that being said, Medicare is so large that it needs to be an online product that allows the procedure to be reviewed. The AUC is that first piece.”
The testing period in 2020 will provide more clear-cut answers. For now, here are some patient access processes that will be affected:
• An order is going to be required for completion of the questions. This is the biggest challenge Pergrem sees for patient access. “The ordering provider will hopefully go through the appropriate channels to answer those questions to select the proper code,” he says.
• Procedure scheduling, including how walk-ins are handled, will change. “We are hoping that our contractor can assist in getting these areas carved out appropriately and feed us data that will be integral to us getting paid properly,” Pergrem says.
The new requirements will affect scheduling, patient access, insurance verification, as well as the revenue cycle in general, says Tammie Myers, regional senior manager at Novant Health Imaging. “It seems this will work very similarly to the auth requirements of other carriers,” Myers observes.
While Medicare is not calling it an “authorization requirement,” it will work mostly the same way. Without the AUC information in place and correctly coded, the hospital will not be paid. “The financial burden lies on us as the rendering hospital,” Myers notes.
The mandatory testing period in 2020 is expected to provide useful data for analysis and correction. This should prevent a huge increase in denials. “However, it’s still possible that there will be revenue loss from this new program,” Myers cautions.
The best course of action for patient access: strategic planning. Leaders should be ready to change the way they handle scheduling and insurance verification. “We should be prepared to make numerous changes to ensure the best patient outcomes are received, and our financial vitality remains intact,” Myers offers.