ACR CEO discusses solution to fight burdensome prior authorizations in medical imaging
The American College of Radiology is intensifying its advocacy efforts against the growing number of prior authorizations required for medical imaging exams, which are creating significant barriers for patients seeking timely care. Dana H. Smetherman, MD, MBA, the newly appointed CEO of ACR, said there are negative impacts of these authorizations on both patients and healthcare providers. One solution ACR supports is appropriate use criteria, which recently appeared to be a dying and unpopular Medicare payment mandate.
"Prior authorization is very burdensome for providers and very frustrating for patients," she said. "We would actually see incorporating appropriate use criteria directly into the electronic health record as a less burdensome way to make sure that only the imaging studies that a patient needs get ordered and are performed."
Is appropriate use criteria a better alternative to prior authorization?
The 2014 Protecting Access to Medicare Act introduced a requirement that referring physicians have proof they consulted appropriate use criteria software to ensure that only necessary imaging studies are conducted. However, the implementation of AUC has faced technical challenges and has been met with resistance from some medical societies due to its increased administrative burden. Medicare removed the requirement from its 2024 Medicare Physician Fee Schedule and the American Society of Nuclear Cardiology has lobbied Congress to repeal the requirement.
Despite these challenges, Smetherman believes that AUC could play a crucial role in reducing low-value imaging, especially in the context of growing radiology staffing shortages.
"While AUC was removed from the 2024 Medicare Physician Fee Schedule, I believe that AUC can help reduce the large number of low-value imaging exams, allowing radiologists to focus on higher-value studies," Smetherman explained.
Incorporating AUC into the EHR system could streamline the process, she added, making it easier for referring physicians to order only the most necessary studies. This would likely satisfy the same goals as current prior authorization requirements, except that decisions would be immediate, transparent and follow guidelines set by the ACR or other physician expert bodies, rather than dictated by an insurance company.
The case for AUC in inpatient settings
Smetherman highlighted the potential benefits of AUC in inpatient settings, where managing the flow of patients through hospitals and ensuring timely access to imaging is critical. Until June, she was chair of the Department of Radiology and associate medical director for medical specialties at the Ochsner Medical Center in New Orleans. As medical director for numerous inpatient specialities, she saw a clear need to get everyone on the same page to reduce the number of low-value imaging tests. Radiologists are sometimes overwhelmed with the number of studies that need to be read and reported, she said.
"I think we may find significant value in the inpatient setting, particularly in reducing unnecessary studies that do not add to patient care," Smetherman said. "This not only benefits the individual patient but also ensures that imaging resources are available for others who need them."
Vermont's pioneering move to eliminate prior authorizations may be a model for the future
In a notable development, the state of Vermont recently passed legislation eliminating prior authorization requirements for some payers, a move that has captured the attention of the medical community. Smetherman said Vermont's medical society reached out to ACR for assistance in developing tools to help primary care physicians make informed decisions in the absence of prior authorization.
"The prior authorization question is an interesting one, and it will be fascinating to see how Vermont's experiment unfolds," Smetherman said. "We're pleased that their medical society reached out to us, and we're ready to provide the necessary support to ensure that patients receive the appropriate imaging studies without unnecessary hurdles."
The ACR has created appropriateness criteria for well over 200 different types of exams on its website. As the college continues to advocate for policies that prioritize patient care, Smetherman said ACR is committed to finding solutions that reduce the administrative burden on healthcare providers while ensuring that patients receive timely and necessary imaging.
"We really do want patients to get the right imaging study so that their questions can be answered and their treatment can be started," she concluded.
Watch other videos where Smetherman discusses various radiology topics:
New ACR CEO outlines key concerns for radiology
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Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com