ACR supports bringing back clinical decision support to combat prior authorizations
The American College of Radiology is throwing its support behind new federal legislation aimed at curbing the increasing burden of prior authorization in medical imaging. The proposed Radiology Outpatient Ordering Transmission (ROOT) Act, introduced in May by Senators Marsha Blackburn, R-Tenn., and Catherine Cortez Masto, D-Nev., could replace prior authorization requirements for advanced imaging with a clinical decision support system based on evidence-based appropriate use criteria (AUC).
Alan Matsumoto, MD, chair of the ACR Board of Chancellors and professor of radiology at the University of Virginia, spoke to Radiology Business about ACR's support for the bill during the American Medical Association meeting in June. He said the bill offers a promising alternative to today’s increasingly time-consuming prior authorization process that often delays necessary patient care. The bill calls for the use of an order entry tool in the electronic health record that informs the referring provider what imaging study is most appropriate for the clinical question they are asking.
"It's based upon appropriate use criteria that is evidence-based to inform the physician on the best advanced imaging study to order for the indication. It will also be embedded in electronic health record, and then in the past, the effort to try to implement this was hindered by too much administrative burden. The new proposal takes away a lot of that administrative burden. It's not real-time adjudication, it allows for retrospective compliance assessment, so the ordering provider feels like it's much easier for them to do," Matsumoto said.
By helping better identify the best test for each patient's needs, this system also would reduce the current large number of inappropriate tests that add unnecessary costs across healthcare spending.
"This is a potential win-win for the government and helps put money back in the pot," he said.
About 3 out of 10 advanced imaging studies ordered are inappropriate and should not have been performed, previous research has shown. By eliminating these, this would help not only cut costs and improve patient diagnosis, but also reduce radiation exposure to patients and reduce the number of exams radiologists are currently reading so they can concentrate on the exams that matter. In the growing shortage of radiologists, this could have a large impact on radiology, reduce burnout and be a better use of limited radiology resources.
"It meets with this current government's desire, reduce waste and cut costs. The prediction is it can save the government close to $2 billion over a decade. And more importantly, I think it saves out-of-pocket expenses for the patients at about $1.4 billion over a decade as well."
A smarter, streamlined process for advanced imaging
The ROOT Act would reinstate the use of clinical decision support tools first proposed under the Protecting Access to Medicare Act (PAMA) in 2014, but never fully implemented due to concerns over administrative complexity and IT integration. Unlike the earlier attempt, the new bill includes important updates, most notably removing real-time adjudication in favor of retrospective compliance assessment. With the integration of artificial intelligence, Matsumoto said the implementation will be much easier than the original proposal from a decade ago.
The administrative burdens of the AUC requirements in PAMA were opposed by the American Society of Nuclear Cardiology (ASNC) and other groups. They celebrated when the AUC requirement was removed by Medicare in 2023 after years of implementation delays and resistance from providers. So, it was not surprising when ASNC announced its opposition to the ROOT Act soon after its proposal. The group actively lobbied against the act in June, while at the the same time ACR members were advocating for it.
"I would suggest to them to keep an open mind," Matsumoto said about the bill's opponents. "It's very different than it was 10 years ago, because you can now apply AI tools to help with these things. Some of our providers actually found it interesting because AI can automatically look up ICD-10 codes and add them to the order based upon the likely diagnosis and the indication for the study. So ultimately it may be more rapid for them in the long run."
More importantly and potentially saving much more staff and physician time, the ROOT Act AUC system would eliminate a large number of insurance company and Medicare prior authorization reviews. ASNC and ACR both agree the rapid rise in prior authorization use is out of control and prevents or slows down care for patients, eats up physician time, and is a major cause of burnout.
"Our orthopedic surgeons and some of our specialists, they said this is great because having to do fewer prior authorizations, appeals and filling out all that paperwork in their teams, it will save everybody time in the long run. With human resources, time is money. It gets to what the current administration is trying to do, reduce waste, and allow people to do what they should be doing at the top of their license, rather than all this administrative burden," Matsumoto said.
The decision support system is based on multidisciplinary, evidence-backed AUC developed by ACR in collaboration with other medical specialties since 1993. The tool provides ordering clinicians with a green, yellow, or red score that indicates the appropriateness of a test based on the indication, streamlining decision-making at the point of care. He said this is especially important for clinicians who are not familiar with what tests are best to order or what the clinical literature says. The ACR AUC website provides a quick-glance way of addressing this.
Proven results could eliminate need for most prior authorization
In a pilot program at the University of Virginia involving a private insurer and its radiology benefits manager, the system showed promise. They looked at exam types that required prior authorization and compared what was approved or denied based on the ACR AUC system.
"We basically said, let's look at all the green scores we get and see if you would've denied any of them in retrospect. It turns out they would not have denied any of them in retrospect. And actually, some of the red scores they actually approved and let go through," Matsumoto said.
This helped with validating the tool’s reliability.
"We took 70% of the orders out of this whole process. So, if you get a green score, you can order that study today. And we had patients that had cancer, patients that had messed up knees or hips that had come to see our oncologists and orthopedic surgeons respectively. They got a green score and they called us and said, 'We'd like to schedule this patient.' And that patient was able to get studied then move forward with the diagnosis and therapy quicker. So, it was a win-win because we eliminated 70% of prior auths for our team to fill out the paperwork, which was a money saver. And then the patients benefit from that as well," he said.
So, the next step if the ROOT Act becomes law would be to push for elimination of the prior authorization process for 70% of common exams, he added.
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: [email protected]