Immediate Legislative Fix to Protect AUC Programs is Critical for Patients, Providers and Taxpayers

The American College of Radiology® (ACR®) calls on Congress to pass a legislative fix for the Protecting Access to Medicare Act (PAMA) appropriate use criteria (AUC) program before the end of the year. Congress previously passed PAMA in 2014, and should act quickly to fix the program.

The PAMA AUC program is an effective and evidence-based program that ensures clinically appropriate imaging. Its use in the private sector is ensuring that patients receive the right imaging at the right time and avoid imaging they do not need.

 
Streamlined Effective Care for Patients AUC CDS		  
The Best Test at the Point of Care: AUC CDS		  
The Right Imaging at the Right Time: AUC CDS
Appropriate use criteria programs are good for patients, providers and taxpayers. Benefits of fully implementing the PAMA AUC policy include:

Estimated $2 billion dollars in savings to Medicare Program for the federal government over a ten-year period.

Significant savings of utilization dollars due to use of AUC in electronic medical record (EMR).

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

Approximately $1.4 billion in savings to Medicare beneficiaries via reduced cost sharing over ten years.

Optimizing patient care by guiding providers’ determinations of a patient’s advanced imaging needs.

Developed by more than 700 medical professionals with continuous updates.

Continued improvements on a program that works.

In 2014, Congress passed PAMA to ensure millions of seniors could maintain access to critical health services. The AUC program was paused by CMS on January 1, 2024, when barriers to implementing the real-time claims processing aspect of the program were encountered.

The legislative fix to the AUC program is simple.

The AUC program can easily be addressed by a simple statutory fix by Congress, removing the real-time claims processing requirement. ACR supports the removal of the real-time claims processing requirement and stands ready to work with Congress to ensure CMS can implement the AUC program.

FAQs

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.
What is the 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.
When and why was the AUC program paused?
  • The 2024 Medicare Physician Fee Schedule final rule , released November 2023, called for a pause to the PAMA AUC program due to continued concerns with the real-time claims processing aspect of the statute.
  • ACR is working with Congress in hopes of a legislative fix before the end of 2024.
What can be done?
  • The real-time claims processing requirement can easily be addressed by a simple statutory change to the law.
Why are providers continuing 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 of workforce shortages, ensuring that exams performed are appropriate and warranted ensures that physicians do not burn out, and that they do not accidentally ignore a critical study because it is buried between many inappropriate studies.