How to prepare for CMS’s Appropriate Use Criteria Program

Published: April 11, 2022 by Experian Health

The Appropriate Use Criteria (AUC) program is due to come into full effect in January 2023 at the earliest. The program was established by the Centers for Medicare and Medicaid Services (CMS) to help providers order the most appropriate diagnostic imaging services. Failure to comply may result in claims denials. Any provider that offers these services to Medicare beneficiaries should amend their clinical and revenue cycle workflows now, to avoid payment penalties when the AUC testing period comes to an end.

This article sets out what providers can do to learn, test and prepare for the AUC program, and what Experian Health is doing to help healthcare providers manage these changes and minimize the risk of denied claims.

What is the Appropriate Use Criteria program?

The AUC program was created through the Protecting Access to Medicare Act of 2014 to help ensure that diagnostic imaging services would only be provided where medically necessary. No one would argue against evidence-based care. However, accessing that evidence can be challenging. Easy-access online tools are intended to make this easier. They have also been shown to reduce the overutilization of high-risk, high-cost imaging services.

Under the program, any time a physician (or a member of their clinical staff) wants to order imaging services such as magnetic resonance imaging (MRI) or computed tomography (CT) for certain Medicare patients, they’ll need to consult an electronic Clinical Decision Support Mechanism (CDSM). This is especially important in an academic teaching environment. This online portal will check the patient’s electronic health record (EHR) and determine whether the order adheres to AUC or not, or whether the AUC consulted was not applicable.

After consulting the CDSM, the ordering physician will need to include the following data on the order they send to the imaging services provider:

  • the CDSM they consulted
  • the ordering provider’s National Provider Identifier
  • whether the service adhered to the applicable AUC or not, or whether no criteria in the CDSM were applicable to the patient’s clinical situation.

Any ordering professionals deemed to be outliers will be required to seek prior authorization. When the program is fully implemented, imaging service providers will need to ensure they have a certificate of compliance to secure reimbursement.

Who will be affected by the AUC program?

The program applies to any provider that orders advanced diagnostic imaging services that are delivered in physician’s offices, hospital outpatient departments, ambulatory surgical centers (ASCs) or independent diagnostic testing facilities. It applies to those that are paid under the Medicare physician fee schedule, hospital outpatient prospective payment system or ASC payment system. It does not apply to Medicare Advantage beneficiaries. Emergencies, inpatient services and certain hardship exceptions are exempt. If any of these exceptions apply, the ordering physician must record them on the claim using the appropriate modifier code.

When do providers need to implement it?

CMS confirmed that there will be no payment consequences for failing to include AUC data until the later of January 2023 or the declared end of the COVID-19 public health emergency. In the meantime, providers are encouraged to implement the program on a voluntary basis, which will help identify pinch points in the claims management workflow. Claims submitted before full implementation may still be subject to denial, so it’s worth getting the process right now to avoid unnecessary rework later.

How can providers “learn, test and prepare” for the AUC program?

Healthcare organizations that may be affected by the AUC mandate should consider the following actions to ensure they are fully prepared by the time the program is fully implemented:

  1. Check the AUC program requirements and identify which service lines and vendors will be affected.
  2. Choose an appropriate Medicare-approved CDSM that closely matches existing EHR and claims management processes. Most EHR vendors will recommend a CDSM that fits seamlessly with their solution. CMS has also provided a list of certified CDSMs, which includes free options. However, these operate as stand-alone systems that will be more challenging to integrate with existing workflows.
  3. Communicate changes to staff. Ensure all referring and rendering providers are aware of and trained on the requirements and encourage dialogue to clarify new ways of working.
  4. Consider the impact on claims management teams, and ensure staff are trained on the new requirements. Healthcare Common Procedure Coding System G-codes and modifiers must be reported in claims alongside primary and secondary diagnosis and procedure codes. Are staff aware of the new codes? Are additional staff needed to process claims and potential rework that may be required after the AUC program is implemented?
  5. Build in time for review, to check that new processes are compliant. Ideally, the CDSM solution will include reporting functions to monitor progress and identify potential outliers that may be subject to prior authorizations later.

If the furnishing provider is different from the ordering provider, the furnishing provider should have a workflow to confirm AUC adherence.

How can digital tools and automation help providers ensure compliance with Appropriate Use Criteria?

While the goal of the AUC program is to improve patient care and help manage the cost to the public purse, there will be an administrative burden for staff. The growing volume and complexity of claims overrule any attempt to manage this manually. Instead, healthcare organizations should look at automating the compliance process to ensure accuracy, prevent denied claims and reduce staff costs.

To help healthcare providers manage these changes, Experian Health enhanced the Medical Necessity application to generate informational alerts when a procedure needs to adhere to AUC or prior authorization for Medicare patients. Users will be able to use this alert as a sign to check the AUC has been adhered to.

These tools also fit well with Claim Scrubber, which reviews every line of each claim to verify that it’s coded correctly and isn’t missing any vital information, before being submitted. Claim Scrubber has also been enhanced to incorporate billing modifiers that will help with overall compliance requirements under the AUC rules.

Preparing for what’s to come

Access to medically necessary services is at the heart of evidence-based care. However, in promoting this, the Appropriate Use Criteria program creates additional tasks for staff that need to be understood and managed efficiently. While there are currently no penalties for non-compliance, providers should use the testing period to proactively implement new processes to determine their efficacy.

As healthcare regulation continues to evolve, healthcare organizations should take a holistic approach to the exchange of information between clinical decision-makers, service providers and payers to lay the groundwork for consistent, accurate and reliable claims.

Find out more about how Experian Health’s Medical Necessity and Claim Scrubber solutions support the claims management process and help healthcare organizations adhere to the Appropriate Use Criteria program.

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