this Appropriate Use Criteria (AUC) Program Full implementation will begin as early as January 2023. This program was established by the Centers for Medicare and Medicaid Services (CMS) to help providers order the most appropriate diagnostic imaging services.Non-compliance may result in Claim Denied. Any provider offering these services to Medicare beneficiaries should now revise their clinical and revenue cycle workflows to avoid paying penalties at the end of the AUC testing period.
This article lists what providers can do to study, test, and prepare for the AUC program, and What Experian Health is doing Help healthcare providers manage these changes and minimize the risk of denied claims.
What is the appropriate use of a standard plan?
The AUC program was created through the Protecting Access to Health Insurance Act of 2014 to help ensure that diagnostic imaging services are provided only when medically necessary. No one will object to evidence-based care. However, obtaining this evidence can be challenging. Accessible online tools are designed to make this easier.They are also proven Reduce overuse of high-risk, high-cost imaging services.
Under the program, anytime a physician (or their clinical staff) wants to order imaging services for certain Medicare patients, such as magnetic resonance imaging (MRI) or computed tomography (CT), they need to consult an electronic clinical decision support mechanism (CDSM). This is especially important in an academic teaching environment. The online portal will examine the patient’s electronic health record (EHR) and determine if the order is in compliance with the AUC, or if the AUC for the consultation does not apply.
After consulting with CDSM, ordering physicians are required to include the following data in the order they send to the imaging service provider:
- CDSM they consult
- Subscription provider’s country provider identifier
- Whether the service complies with the applicable AUC, or whether the criteria in the CDSM apply to the patient’s clinical situation.
Any ordering professionals deemed outliers must be authorized in advance. When the program is fully implemented, imaging service providers will need to ensure they have a certificate of compliance to ensure reimbursement.
Who will be affected by the AUC program?
The program is available to any provider ordering advanced diagnostic imaging services delivered in a physician’s office, hospital outpatient department, ambulatory surgery center (ASC) or independent diagnostic testing facility. It applies to charges paid under the Medicare Physician Fee Schedule, the Hospital Outpatient Expected Payment System, or the ASC Payment System. It does not apply to Medicare Advantage beneficiaries. There are exceptions for emergencies, inpatient services and certain hardship exceptions. If any of these exceptions apply, the prescribing physician must record them in the claim using the appropriate modifier code.
When does a provider need to implement it?
CMS confirmed that there will be no payment consequences for excluding AUC data until late January 2023 or until the declared COVID-19 public health emergency ends.At the same time, providers are encouraged to implement the program on a voluntary basis, which will help determine the Claims Management Workflow. Claims filed prior to full implementation may still be rejected, so it’s worth getting started right away Avoid unnecessary rework later.
How do providers “Learn, Test, and Prepare” for the AUC Program?
Healthcare organizations potentially affected by AUC mandates should consider taking the following actions to ensure they are fully prepared when the plan is fully implemented:
- Check AUC Program Requirements And determine which service lines and suppliers will be affected.
- Select the appropriate Medicare-approved CDSM Works closely with existing EHR and claims management processes. Most EHR vendors will recommend a CDSM that fits seamlessly with their solution. CMS also provides List of certified CDSMs, which includes a free option. However, these operate as standalone systems and integrating with existing workflows will be more challenging.
- Communicate changes to employees. Make sure all referral and rendering vendors are aware of these requirements and trained, and encourage dialogue to shed light on new ways of working.
- Consider the impact on the claims management teamand ensure that employees are trained on the new requirements. Healthcare General Procedure Coding System G-Codes and Modifiers Must be reported in claim along with major and minor diagnostic and procedural codes. Are employees aware of the new code? Will additional personnel be required to handle claims and potential rework that may be required after the AUC program is implemented?
- Establish a review in a timely manner, Check the new process for compliance. Ideally, a CDSM solution will include reporting capabilities to monitor progress and identify potential outliers that may require prior authorization later.
If the furniture supplier is different from the ordering supplier, the furniture supplier shall have a workflow for confirming AUC compliance.
How can digital tools and automation help suppliers ensure compliance with appropriate usage standards?
While the goal of the AUC program is to improve patient care and help manage the cost of public funds, staff will bear the administrative burden. The growing volume and complexity of claims overwhelms any attempts at manual management. Instead, healthcare organizations should look to automate compliance processes to ensure accuracy, prevent denied claims and reduce staff costs.
To help healthcare providers manage these changes, Experian Health has enhanced medical necessities The application generates informational alerts when the procedure needs to comply with the AUC or a Medicare patient’s prior authorization. Users will be able to use this alert as a flag to check if AUC is being complied with.
These tools are also great for claim scrubber, it reviews every line of every declaration before committing to verify that it is coded correctly and that no important information is lost. Claim Scrubber has also been enhanced to include billing modifiers, which will help meet overall compliance requirements under the AUC rules.
Prepare for what’s to come
Access to necessary medical services is at the heart of evidence-based care. However, in facilitating this, the appropriate use of standard programs creates additional tasks for employees who need to be understood and managed effectively. While there are currently no penalties for non-compliance, suppliers should use the beta period to proactively implement the new process to determine its effectiveness.
As healthcare regulations continue to evolve, healthcare organizations should take a holistic approach to exchanging information among clinical decision makers, service providers, and payers, laying the groundwork for: Consistent, Accurate and Reliable Statements.
Learn more about Experian Health medical necessities and claim scrubber The solution supports the claims management process and helps healthcare organizations comply with appropriate use standard programs.
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post How to Prepare for a Standard Plan for Proper Use of CMS first appeared in Healthcare Blog.
