They may call it compliance but if you think it through, you can really call it obedience — as long as you stay contracted with them and accept their reimbursement.
In January 2020, the Centers for Medicare & Medicaid Services (CMS) originally mandated a requirement that any provider ordering an MRI, CT scan, or a nuclear study for a Medicare Part B outpatient had to first consult Appropriate Use Criteria (AUC) and use a CMS-qualified Clinical Decision Support Mechanism (CDSM) before an order could be approved otherwise, the facility will not be paid.
CMS later announced in the CY 2022 Physician Fee Schedule Final Rules that delays their original payment penalty phase to a later date beginning in January 2023.
No matter when and how this is to be enacted, as I understand this, doctors who want to order these tests must reference a government criteria guide to justify their decision for it. If they don’t do this, their order will not be approved, and the facility will not be paid.
Doctors who want to order certain tests must reference a government criteria guide to justify their decision for it. If they don’t do this, their order will not be approved, and the facility will not be paid. Click To Tweet
I practice as a direct care physician and advocate for an alternative system outside of the traditional insurance model. I’m not looking to change the entire healthcare world, just the part I interact in – the outpatient setting – and more specifically, the patient in front of me!
My transition to direct care didn’t happen overnight. When I dropped all third party payors, I was still able to get my patients the care they needed. They were still able to get outpatient diagnostic tests and labs as well as their medications. This is because I worked with other physicians, facilities, employer groups who realized the current outpatient healthcare environment represented a rigged game they could no longer afford to play.
When I dropped all third party payors, I was still able to get my patients the care they needed. Click To Tweet
So, let me read that again, if a physician doesn’t get the authorization, “the facility doesn’t get paid.”
I ask my fellow physicians: Why are you doing their work? You don’t work for the facility, but you (or an employee you pay) must do additional work so that they can be paid.
It’s bad enough you have to do these things so that YOU can be paid for services you render. Now you have to do these things in order for other corporate entities to be paid? Why? You aren’t providing the services, they aren’t being done in your office, and you aren’t even getting reimbursed.
I ask my fellow physicians: Why are you doing their work? You don't work for the facility, but you (or an employee you pay) must do additional work so that they can be paid. Click To Tweet
Now consider the following scenario. You put in the order, get the authorization and the patient gets the test. Then you get a phone call from the patient saying “I had to pay out of pocket because it went to my deductible”, or “I didn’t get it because I have to pay out of pocket”.
What if you had the patient ask for a cash price, which would not have needed an authorization? One where the cost was much lower (in some cases up to 50% less)? If your patient is paying for it anyway since it’s going towards their deductible, why not save yourself some time and your patient some money?
When you contract with third party payors, you are being conditioned to comply with their rules and obey their orders (if you want to get paid). Each new rule that is put in place (e.g. eRx, EHR, PQRS, Meaningful Use, MACRA, MIPS) is just another Pavlovian training exercise to gain your compliance.
The question is not “When will this stop?” The question is “What’s next?”
But who is REALLY running your business?