Imaging Clinical Decision Support: The Medicare Mandate - Prepared for National Decision Support...

Imaging Clinical Decision Support: The Medicare MandatePrepared for National Decision Support Company

Imaging Performance Partnership

Erin LaneSenior AnalystImaging Performance Partnership, Advisory Board [email protected]

March 9, 2017

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of U.S. News and World Report “Honor Roll” hospitals are members

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9,500+

Through the breadth of our network andthe depth of our expertise, we forge andfind the best practices that

• Help our members set course

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Start withbest practices

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OPERATIONS

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Then hardwire those insights into your organization with research, technology, and consulting


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CDS Comprised of Two Distinct Parts

Source: Imaging Performance Partnership interviews and analysis.

IT ToolElectronic platform that

makes guidelines accessible

Appropriate Use CriteriaClinical guidelines

Clinical Decision Support +=


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Medicare Legislation Mandates CDS1 for ImagingProvider Requirements and Legislative Recap

Source: “Protecting Access to Medicare Act of 2014” Congress of the United States of America, April 1, 2014; Imaging Performance Partnership interviews and analysis.

1) Clinical decision support.2) Only Medicare fee-for-service.3) National provider identification number.

Legislation in Brief: Protecting Access to Medicare Act (2014)

Providers must indicate that the ordering clinician used an approved decision support mechanism to consult appropriate use criteria for all applicable outpatient advanced imaging exams for Medicare fee-for-service beneficiaries

Ordering Provider Requirements• Consult appropriate use criteria

(AUC) via CDS for Medicare beneficiaries2

• For outpatient advanced imaging exam (CT, MR, PET, nuclear medicine) orders

Furnishing Provider RequirementsSubmit documentation of ordering provider use on Medicare claim:

• CDS mechanism consulted• Adherence to AUC

• NPI3 of ordering professional

Imaging order


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A Brief History and What’s to ComeProvider Consultation and Documentation Required by January 1, 2018

Source: Centers for Medicare and Medicaid Services, CMS.gov; Imaging Performance Partnership interviews and analysis.

1) Protecting Access to Medicare Act.

Regulatory Timeline for Clinical Decision Support

April 2014 PAMA1 signed into law, requiring provider use of AUC via CDS for advanced imaging

November 2015MPFS2 CY 2016 final rule established appropriate use criteria approval process

November 2016MPFS CY 2017 final rule established CDS mechanism requirements and approval process, clinical priority areas

January 1, 2018Ordering providers must consult AUC through qualified CDS; to receive payment, furnishing must submit claims-based documentation

January 1, 2020Ordering providers identified as outliers, may be required to obtain preauthorization

Today


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For the First Time, More Knowns Than UnknownsMedicare AUC Program Beginning to Taking Shape


CDS Components Yet to Be Determined

AUC approval process: Provider-led entities may qualify to create, modify guidelines

Vendor (mechanism) approval process: Requirements for mechanisms set; first list of approved mechanisms to be released by July 2017

Furnishing provider penalties• Imaging claims without documentation

will be denied, meaning no reimbursement for professional or technical components

• But will CMS instead implement a penalty for the first year?

Claims-based reporting• CMS must create new claims form to

enable proper documentation

Outlier provider status: How will CMS calculate outliers? How long with the outlier status remain?

Provider deadline: January 1, 2018 for ordering and furnishing providers

CDS Components Finalized More Clarification Needed


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Qualified Provider-Led Entities to Create, Modify AUCAll Providers Use Criteria Developed by PLEs1 to Comply With Mandate


1) Provider-Led Entities.

Rather than approving individual criteria, CMS approves groups, or “provider-led entities” to create, modify, endorse AUC

Qualified PLEs As of July, 2016

American College of Cardiology Foundation

American College of Radiology

Brigham and Women’s Physician Organization

CDI Quality Institute

Intermountain Healthcare

Massachusetts General Hospital, Radiology

National Comprehensive Care Network

Society for Nuclear Medicine and MolecularImaging

University of California Medical Campuses

University of Washington Physicians

Weill Cornell Medical Physicians Organization

To comply with the mandate, ordering providers must use AUC from qualified PLEs

CMS will release list of newly approved PLEs by June 30 of every year, so the number of PLEs will grow over time

Appropriate User Criteria Basics


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Becoming a Qualified PLESix Requirements, New Applications Accepted Annually


Provider-Led Entities Qualification Requirements

Finalized Definition for Provider-Led Entity“An organization comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care.…all AUC developed or endorsed by that provider-led entity will be considered to be specified AUC.”

Related Deadlines

Follow robust evidentiary-review process for criteria

Publically disclose conflicts of interest

Publically post all AUCs and evidence on website

Grade criteria in terms of strength of evidence

Publically outline AUC development process

AUC development process led by multidisciplinary team(s)

Jan 1: Applications due to CMS

June 30: CMS will release list of qualified provider-led entities on website


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In the Waiting Game for CDS Mechanisms Requirements Finalized and Deadline Passed but Awaiting Approved List


Providers must use qualified CDSM to comply with mandate

Sample CDSM Requirements Incorporates reasonable scope of AUC

Incorporates AUC from more than one qPLE

Makes AUC, support documents available

Determines appropriateness of imaging exams

Documents provider use with unique identifier

Ability to update AUC in reasonable timeframe

Stores necessary information for six years

Provides aggregate feedback annually to provider

Compiles with privacy laws requirements

CDS Mechanism Basics

Mechanisms must adhere to full set of requirements

CDSM Dates for Providers to KnowMarch 1: Application deadline for 2017 approval

June 30: CMS to publish list of approved CDSMs


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Two Levels of CDSM ApprovalThe Provider’s Guide to CDSM Approval


Level 1: Preliminary Approval

Level 2: Full Approval

ApprovalDefinition

CDSM does not meet all requirements, but has a clear plan in place to meet all requirements by January 1, 2018

CDSM meets all requirementson date of application: March 1, 2017

Does thisCDSM meet all requirements?

• No• Submitted clear plan to meet all

requirements by January 1, 2018

Yes

Will providers using this CDSM on January 1, 2018 comply with the mandate?

• No• Preliminarily approved CDSMs

become fully approved after demonstrating adherence to all requirements

• CDSMs that cannot meet all requirements by January 1, 2018 required to notify providers

Yes


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Priority Clinical Areas Used to Determine Outliers Targeted Clinical Groupings to Evolve, Expand With Time


1) Not included in proposed rule.2) Traumatic and non-traumatic.3) Primary or metastatic, suspected or diagnosed.

Finalized Priority Clinical Areas1 Coronary artery disease1

2 Suspected pulmonary embolism1

3 Headache2

4 Hip pain1

5 Low back pain

6 Shoulder pain1

7 Cancer of the lung3

8 Cervical or neck pain

CMS to increase number, scope of areas annually

Priority Clinical Area Used to Identify Referrer OutliersCMS will analyze imaging utilization and CDS compliance within priority clinical areas (PCAs) to identify outlier referrers by 2020 and set scope requirements for AUC in CDSMs

CMS selected diagnostic groups with highest associated advanced imaging volumes


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Holding Providers Accountable for AppropriatenessProcess Penalties for Ordering Providers, Financial for Furnishing


1) As required by the law, but CMS has not yet finalized.

Ordering Provider Requirements• Consult appropriate use criteria (AUC)

via CDS for Medicare beneficiaries2

• For outpatient advanced imaging exam (CT, MR, PET, nuclear medicine) orders

Furnishing Provider RequirementsSubmit documentation of ordering provider use on Medicare claim:• CDS mechanism consulted

• Adherence to AUC

• NPI3 of ordering professional

Imaging order

Penalty for Noncompliance1 Penalty for Noncompliance1

Classified as an outlier, required to obtain preauthorization for Medicare patients

Claims denied and reimbursement withheld; applies to both professional and technical components


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QUESTIONSErin LaneSenior AnalystImaging Performance Partnership The Advisory Board [email protected]


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Best Practices for CDS Implementation Advisory Board Resources to Support Your CDS Strategy

Source: Imaging Performance Partnership interviews and analysis.

FOR ALL RESOURCES on this topic, visit advisory.com/ipp/CDS

Toolkit for Successfully Implementing Imaging Clinical Decision SupportComprehensive set of tools that map to tactics for thoughtful and effective implementation of imaging CDS

Playbook for Implementing Clinical Decision SupportThe imaging leaders guide to successful CDS implementation, including case studies from successful organizations

Imaging Clinical Decision Support: The Medicare Mandate

Thank You!Send Additional Questions to [email protected]

Erin LaneSenior AnalystImaging Performance Partnership The Advisory Board [email protected]


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Imaging Clinical Decision Support: The Medicare Mandate - Prepared for National Decision Support...

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Transcript of Imaging Clinical Decision Support: The Medicare Mandate - Prepared for National Decision Support...