Changes Results of PAMA; New Requirements Begin Jan. 2018
What is AUC? AUC is defined as criteria developed or endorsed by national professional medical specialty societies, or other provider-led entities, to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition for an individual. To the extent feasible, AUC must be evidence-based. It is anticipated that by the end of June 2017, CMS will announce qualified clinical decision support mechanisms (CDSMs) or software that provide AUC information to the provider and that will assist the provider in making the most appropriate treatment decision for a patient’s specific clinical condition.
The PAMA legislation mandates that AUC be consulted for all advanced diagnostic imaging services. CMS has identified “priority clinical areas” such as CAD, suspected PE, headache, cancer of the lung, and various common areas of pain (hip, low back, and shoulder) but only for the purposes of identifying ordering professionals who are outliers and who may be failing to comply with AUC. The statute requires the identification of outlier ordering professionals, who will be subject to a prior authorization requirement beginning on January 1, 2020.
This news alert is created by the attorneys Healthcare Practice Group at Friday, Eldredge & Clark, LLP. The information provided is not a substitute for legal advice and should be considered for general guidance only. Please contact one of our attorneys for specific legal advice regarding this matter.