Medicare releases guidance on new model targeting ‘wasteful’ radiology procedures
The Centers for Medicare & Medicaid Services recently released new guidance on a pay model targeting unnecessary interventional radiology services.
CMS first announced the Wasteful and Inappropriate Service Reduction (or “WISeR”) initiative in June, which is set to begin Jan. 1 across six states. WISeR will focus on over a dozen services Medicare says are often subject to fraud, including image-guided decompression of the spine, epidural steroid injections for pain management, and percutaneous vertebral augmentation.
“By focusing on services vulnerable to fraud and waste, the model seeks to decrease clinically inappropriate care and protect beneficiaries while ensuring continued access to appropriate services,” CMS said in the guidance, which is dated Oct. 10 and also was shared by the American Hospital Association Wednesday.
In the new document, CMS explains how interventional radiology providers can submit prior authorization requests to the federal payment program for seniors, including what evidence is required. It also details how determinations will be made, among other insights. For instance, radiologists delivering percutaneous vertebral augmentations, or PVAs, which use X-ray guidance to inject bone cement into the fractured vertebrae to relieve pain, must meet several conditions.
For physicians treating pain stemming from osteoporosis, vertebral collapse or spinal-compression fractures, the pain must be acute (lasting less than 6 weeks) or subacute (6 to 12 weeks). Radiology providers will need to have documented evidence, either through advanced imaging such as bone marrow edema on MRI or bone-scan/SPECT/CT uptake. Patients also must be hospitalized with severe pain or out of the hospital with moderate to severe pain, despite optimal nonsurgical management, with other potential scenarios also eligible for reimbursement.
WISeR is slated to last five years, operating in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. Medicare is offering incentives to technology firms to help curb utilization of these services using artificial intelligence.
The Society of Interventional Radiology formally announced its opposition to WISeR in September. SIR, which represents over 8,000 members of the specialty, said the initiative flies in the face of previous Medicare promises to reduce administrative requirements burdening radiologists and other physicians. The society highlighted robust clinical evidence underscoring the benefits of vertebral augmentation.
SIR estimated WISeR will kill nearly 100 seniors who can’t receive PVAs due to care delays, based on data from previously published analyses.
“Even under conservative assumptions, these numbers represent a significant and preventable loss of life attributable solely to administrative delay,” SIR President Robert A. Lookstein, MD, and CEO Eve Lee, MBA, wrote last month. “Moreover, this estimate reflects only a fraction of the total Medicare population that undergoes vertebral augmentation each year. Scaling the impact across thousands of patients could result in hundreds to thousands of avoidable deaths nationwide.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.