Physicians want Medicare Advantage plans to stop auto-denying imaging services

Physicians want Medicare Advantage plans to stop automatically denying coverage for imaging services, recently voicing their frustration in a letter to the feds. 

In April 2023, the Centers for Medicare & Medicaid Services adopted new guardrails aimed at curbing private health plans’ deployment of computer algorithms to limit seniors use of healthcare services. However, the move did not do the job, and CMS is now working to further refine its rules. 

The agency in December proposed updates to Medicare Advantage. This included forbidding plans from automatically denying coverage of basic benefits without first making an individual determination of medical necessity. CMS also is proposing to prohibit prior authorization criteria that “does not have any clinical benefit and, therefore, exists to reduce utilization of the item or service,” the American College of Nuclear Cardiology reported Feb. 2. 

ASNC said it has seen such scenarios play out in the past, with payers auto-denying coverage of cardiac PET (positron emission tomography) and instead pushing for coronary CT angiography.

“Cardiovascular disease is complex and because there are many different diagnostic tests and treatment approaches, there can be confusion and disagreement, even among clinicians, on the most appropriate test or course of treatment,” cardiologist Panithaya Chareonthaitawee, MD, president of the ASNC, wrote in a Jan. 27 letter to CMS. “One thing clinicians and policymakers should all agree on is that each patient is different, and, therefore, no single imaging modality should ever be considered the first-line test in every patient.”  

ASNC and other societies have invested time and expertise into developing appropriate use criteria and quality measures to help guide the selection of imaging exams, she emphasized. 

“Yet, these guidelines are often disregarded by payers that use restrictive algorithms that uniformly guide patients to the same diagnostic test regardless of individual characteristics,” Chareonthaitawee added. 

CMS also is proposing greater disclosure requirements by Medicare Advantage organizations. This would include reporting the percentage of prior authorizations broken down by item and service, instead of at aggregate. Officials hope this will help to bring MA better in line with traditional Medicare and eliminate bias in the use of artificial intelligence to review requests for imaging and other services. 

The American College of Radiology also submitted comments on the proposal Jan. 24, voicing support for these policy changes. ACR pointed to a 2021 study, which found that radiology is among medical specialties with the highest rate of services subjected to prior authorization in Medicare Advantage. 

“Proposals included in this regulation would provide much-needed transparency for not only MA beneficiaries, but hospitals and providers administering their care,” wrote CEO Dana Smetherman, MD, MBA, MPH. “As such, ACR supports these proposed policies."

The college urged CMS to consider utilizing clinical decision support to adhere to these proposals. Such physician-developed and evidence-based criteria could help to reduce administrative burdens on radiology providers, along with producing $700 million in potential savings to Medicare by reducing unnecessary imaging orders. 

CMS was accepting comments on the proposed rule through Jan. 27. You can find further details and read additional comments here. The rule, originated under the previous presidency, is now in the hands of the Trump administration, which will decide next steps and whether to move forward, ASNC reported.