AUC Programs Ensure Patients Receive the Right Imaging at the Right Time

The Protecting Access to Medicare Act (PAMA) appropriate use criteria (AUC) program is an evidence-based delivery approach that is good for patients, providers and taxpayers. The program has not been repealed but has been paused while Congress considers legislative improvements to the program. Utilizing AUC improves health outcomes, supports decision making, fosters an educational environment for providers and results in cost saving care.

The American College of Radiology® (ACR®) and the Centers for Medicare and Medicaid Services (CMS) strongly urge providers that have already implemented clinical decision support (CDS) programs to continue using them to make informed decisions on advanced imaging.

Benefits of the AUC program include:

Supporting physicians and non-physician providers (such as Nurse Practitioners and Physician Assistants) to make the best clinical decisions around appropriate use of imaging.

Optimizing patient care by guiding providers’ determinations of a patient’s advanced imaging needs using physician-developed criteria.

Providing enhanced diagnostic accuracy, reducing delays in access and improving health outcomes.

Fostering an educational environment by guiding providers on imaging tests for patient needs.

Reducing unnecessary care and cost by ensuring that imaging services performed are appropriate and warranted.

Savings of potentially $700 million annually to the Medicare program1.

Alternative cost-saving solutions could hurt providers and Medicare patients.

Prior authorization imposes tremendous administrative burdens on physician practices and shifts costs onto physicians. In addition, it takes medical decisions out of doctors’ hands and may delay or deny lifesaving care to those who need it.

Continuing to support the use of AUC.

ACR encourages the continued use of AUC via Clinical Decision Support. CDS ensures patients receive the right imaging at the right time, and helps to avoid imaging they do not need.

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AUC FAQ

What are appropriate use criteria (AUC)?
  • These are physician-developed guidelines clinically oriented to guide decision making about when a medical procedure/service/test would be appropriate or not, and which exam or procedure is most appropriate for the patient’s condition, illness or injury.
  • AUC are created and maintained by professional societies/other entities.
Why are the ACR’s AUC so useful?
  • The ACR Appropriateness Criteria®, ACR’s AUC guidance, are multispecialty, physician-developed, evidence-based and transparent. They are considered the most comprehensive for imaging.
  • In 2023, ACR’s AUC provided 233 diagnostic imaging and interventional radiology topics with over 1,100 variants and, for Diagnostic Imaging topics, there were 3,000 clinical scenarios.
  • The guidelines are developed and reviewed annually by expert panels in diagnostic imaging and interventional radiology. Each panel includes leaders in radiology and other specialties.
What is Protecting Access to Medicare Act (PAMA)?
  • In 2014, Congress passed the Protecting Access to Medicare Act (PAMA) to ensure millions of seniors could maintain access to critical health services.
How are PAMA and the AUC program connected?
  • PAMA requires an AUC consult to be performed via a CMS-qualified clinical decision support mechanism (qCDSM) when ordering advanced diagnostic imaging for Medicare patients.
How does AUC save money and benefit Medicare?
  • The process reduces and/or eliminates inappropriate advanced imaging services from being performed, thus saving Medicare money. If the PAMA AUC program is implemented, CMS estimates a savings of potentially $700 million annually to the Medicare program1. According to an analysis by The Moran Company (TMC), the savings to beneficiary cost sharing is estimated to be roughly $1.4 billion over ten years.
When and why was the PAMA AUC program paused?
  • The PAMA AUC program has not been repealed, but was paused by Congress on January 1, 2024, while Congress considers legislative improvements to the program specifically around the real-time claims processing aspect of the statute. The American College of Radiology® (ACR®) and the Centers for Medicare and Medicaid Services (CMS) strongly urge providers that have already implemented clinical decision support (CDS) programs to continue to use them during this pause.
What can be done?
  • The real-time claims processing requirement can easily be addressed by a simple statutory change to the law.
Why should providers continue to use AUC?
  • The PAMA AUC law has not been repealed, only paused.
  • CMS encourages the continued voluntary use of CDS tools.
  • Providers will be better prepared to meet the AUC mandate when a legislative fix is implemented, and the program moves forward.
What happens if there isn’t a legislative fix? Why should providers continue to invest in AUC programs and technology?
  • Regardless of the CMS AUC mandate, this CDS system has numerous benefits for providers and patients.
  • While the PAMA statute only applies to imaging performed in physician offices and hospital outpatient settings, hospital systems can use CDS for inpatient care as well, leading to more efficient care for all hospital patients.
  • Compared to alternatives such as prior authorization, which imposes huge administrative burdens on physician practices and shifts costs onto physicians, AUC systems optimize patient care by guiding providers’ determinations of a patient’s advanced imaging needs. In an era where workforce shortages demand solutions, CDS empowers providers to order the most appropriate exams and helps prevent critical findings from being delayed .

1 https://public-inspection.federalregister.gov/2023-14624.pdf