Included within the many changes to physician payment in HR2, is one provision that may surprise people; a subset of Medicare physicians will be required to receive prior authorization to conduct imaging services.
Beginning with 2017, and in consultation with stakeholders, the Secretary will identify ordering professionals with low adherence to applicable [appropriate use criteria] AUC(s) (“outliers”) based on two years of data. Beginning January 1, 2020, outlier physicians shall be subject to prior authorization for applicable imaging services. Not more than five percent of ordering physicians can be subject to prior authorization. The legislation provides CMS with $5 million in each of 2019, 2020, and 2021 to carry out the prior authorization program.
On the one hand, limiting the use of unnecessary services is a good way to ensure only cost effective services are provided. The question is how well the government can adequately target these physicians. Will it be able to distinguish between physicians who are specialists in providing imaging for complex patients compared to those who are unnecessarily providing imaging services to patients who do not really need it? On the ground this determination may be feasible, but it may be more difficult to do using claims data or other sources. Physicians and patients will grumble about this prior authorizations; whether their concerns are valid will depend on how effectively Medicare can identify outlier physicians.