Radiology Digest – August 22, 2023

August 18, 2023

Radiology Digest: News from the week of August 22, 2023.

AnchorAnother House Bill Takes Aim At Prior Authorizations

By Andrew Cass | August 16, 2023 | Included in Radiology Digest – August 22, 2023

Maryland Rep. Mark Green has introduced a bill targeting prior authorization requirements in Medicare and Medicare Advantage, as well as prior authorization fixes for Medicare prescription drug plans. 

The legislation would require that board-certified physicians in the relevant specialty are the ones making prior authorization determinations, according to an Aug. 15 news release from Mr. Green’s office. Medicare, Medicare Advantage and Medicare Part D plans would be directed to comply with requirements that restrictions must be based on medical necessity and written clinical criteria, as well as additional transparency obligations. 

A number of bills aiming to reform the prior authorization process have been introduced in the House this year. 

On July 31, two representatives introduced gold-card legislation that would exempt qualifying providers from prior authorization requirements for Medicare Advantage plans. 

Another bill, which would establish an electronic prior authorization process and require Medicare Advantage plans to report to CMS the extent of their use of prior authorization and the rate of approvals or denial, was included in a package of healthcare legislation that passed the House Ways and Means Committee on July 26 and is headed to the full House for consideration. 

To read more, go to Becker’s Payer Issues.


Fearing Delays, American College of Radiology Urges CMS Not to Leave PET Payment Decisions Up to MACs

By Marty Stempniak | August 16, 2023 | Included in Radiology Digest – August 22, 2023

The American College of Radiology is “strongly” urging the Centers for Medicare & Medicaid Services (CMS) not to leave positron emission tomography-related reimbursement decisions to the discretion of local Medicare Administrative Contractors.

ACR voiced its concerns in comments submitted to the lead medical officer of CMS on Tuesday. The agency in July proposed lifting the longstanding national coverage determination that limits patients to one amyloid-detecting PET scan in their lifetime. Instead, CMS would permit MACs to make the call.

“ACR strongly urges CMS to reconsider leaving coverage determinations to the discretion of the local MACs and instead implement a national coverage ruling,” CEO William T. Thorwarth Jr., MD, wrote Aug. 15. “If left to local determination, a final ruling for coverage of ‎Aβ PET could be significantly delayed and highly variable across geographic regions, further [exacerbating] existing inequities to access. Swift and broad coverage of Aβ PET is imperative at this time when anti-amyloid therapies are being approved by the Food and Drug Administration and highly sought after by patients and their families.”

Thorwarth and the college believe there is sufficient evidence to end the ongoing “coverage with evidence development” determination and move instead to nationwide reimbursement for beta-amyloid PET. ACR wants CMS to ensure beta-amyloid PET payment both for initial diagnostic evaluation of Alzheimer’s and other cognitive decline, along with follow-up to gauge the new therapies’ effectiveness, where appropriate.

The college has worked with CMS over the last decade to strengthen evidence of the importance of PET in treating this patient population. It sponsored the Imaging Dementia—Evidence for Amyloid Scanning (IDEAS) study and the follow-up New Ideas analyses to help fulfill coverage requirements from the agency. Thorwarth and colleagues also want an update on the status of the latter, “as the proposed decision lists this study as inactive.” As of July 27, the study had enrolled 4,414 participants, of whom 3,539 had received scans.

“Without the insights provided by a diverse cohort [as New IDEAS intends to do], the clinical utility and effectiveness of beta-amyloid PET is less likely to be fully understood,” the letter stated.

ACR said it has worked with Medicare Administrative Contractors in the past on PET pay decisions, and it doesn’t want patients to experience any delays in receiving these crucial exams.

“We acknowledge that the MACs have experience with extending coverage for PET scans for non-oncologic indications,” Thorwarth wrote. “However, given the importance of the findings from beta-amyloid PET imaging studies, ACR is concerned about the potential delay in coverage decisions by MACs and variations in local coverage that may result in health equity-related access differences due to difference coverage decisions by each MAC.”

Read the whole letter from ACR here. CMS was accepting comments on the proposal until this week, with the college anticipating a final decision in October.
To read more, go to Radiology Business.


UnitedHealthcare’s Commercial Plan Prior Authorizations Cuts by Category

By Andrew Call | August 15, 2023 | Included in Radiology Digest – August 22, 2023

UnitedHealthcare is cutting 20 percent of its prior authorizations in two waves. The first cuts take effect Sept. 1, and the second phase goes into effect Nov. 1. 

Here are the number of cuts UnitedHealthcare is making to its commercial plan prior authorization requirements, broken down by category. See the individual codes being eliminated here.  

Effective Sept. 1
 Durable medical equipment/orthotics/prosthetics: 6Hysterectomy: 2 Spine surgery: 4Genetic testing: 220Breast reconstruction (non-mastectomy): 1Site of service: 107
Effective Nov. 1 
 Cardiology: 2Radiology: 66Unclassified: 1Outpatient therapies: 53
To read more, go to Becker’s Payer Issues.


CMS Officially Drops Fee For Independent Dispute Resolution Back to $50

By Marty Stempniak | August 15, 2023 | Included in Radiology Digest – August 22, 2023

The Centers for Medicare & Medicaid has officially dropped the per-party fee for resolving payment disputes under the No Surprises Act back down to $50, the agency announced Friday.

CMS revealed the change in a FAQ fact sheet, noting that it also is lifting restrictions forbidding physicians from “batching” together similar claims in a single dispute. The update comes in response to a Texas judge’s ruling, which temporarily paused the IDR process and struck down two key pieces of legislation aimed at reining in surprise medical bills.

“These FAQs are not announcing the reopening of the Federal IDR portal to submit new disputes,” CMS said Aug. 11. The departments [of Health & Human Services, Labor and Treasury] intend to reopen the portal to permit the submission of new disputes soon and will notify interested parties at that time.”

CMS is reverting the fee from $350 back to $50, where it will remain for disputes initiated on or after Aug. 3, until the departments decide to set a new amount. The cost will remain $350 for already-paid administrative fees pertaining to disputes initiated between Jan. 1 and Aug. 2 of this year, and the court order does not require refunds for such invoices. However, CMS is ordering dispute-resolution entities to cancel outstanding, unpaid invoices—relating to any disputes initiated in 2023—and resend replacement IOUs with the $50 fee.

Find further details in the frequently asked questions document here.

To read more, go to Radiology Business.


27 States with Concerning Rates of Procedural Medicaid Terminations, per CMS

By Rylee Wilson | August 14, 2023 | Included in Radiology Digest – August 22, 2023

CMS warned 36 states they were not meeting federal requirements for Medicaid call center wait times, application processing timelines and rates of procedural terminations. 

On Aug. 9, the agency sent letters to Medicaid directors in all 50 states and the District of Columbia, evaluating states’ performance on Medicaid call center wait times and call abandonment rates, rates of procedural terminations, and the average wait time for applications to be approved. 

CMS warned Medicaid directors in 27 states and Washington, D.C. their rates of procedural terminations — Medicaid beneficiaries removed from the paper because of missing paperwork or other red tape, rather than being determined ineligible for the program — were too high. 

“While CMS recognizes the significant steps that states have taken to prepare for unwinding and [simplifying] renewal processes, we urge you to take further action to reduce the number of terminations for procedural reasons as quickly as possible by adopting strategies to increase ex parte renewal rates, to support enrollees with renewal form submission or completion, and to facilitate reinstatement of eligible individuals disenrolled for procedural reasons quickly,” Annie Marie Costello, deputy director of CMS’ Center for Medicaid & CHIP Services, wrote to state Medicaid directors. 

The letters used May unwinding data states reported to CMS. Several states did not report data to the agency or had not yet begun the process of redetermining Medicaid members’ eligibility in May. 

See the 27 states, go to Becker’s Payer Issues.


Google Health, Radiology Vendor Seeks Regulatory Approval of AI as Independent Mammography Reader

By Marty Stempniak | August 14, 2023 | Included in Radiology Digest – August 22, 2023

Google Health is working with radiology vendor iCAD to seek approval for the use of artificial intelligence as an independent breast image reader, the two announced Monday.

Under terms of the agreement, iCAD will integrate Google’s AI technology into its ProFound Breast Health Suite for 2D Mammography over the next 20 years. Once the product is approved, providers will be able to use the mammography tool “as an independent reader for breast cancer screening” across the globe, the companies said.
“The conventional double-reading workflow utilized by most countries, where mammograms are assessed by two separate radiologists, has become increasingly challenging due to the scarcity of radiologists worldwide,” iCAD president and CEO Dana Brown said in an Aug. 14 announcement. “As the global radiologist shortage continues to impact patient care, healthcare organizations are seeking clinically proven solutions to help their radiology departments run more efficiently and adeptly handle the workload in front of them.”

The firms first partnered in November 2022, when Google licensed breast cancer AI technology to iCAD. This led to the recently amended “development and commercialization agreement.” Google’s mammography AI system outperformed six human readers, scoring an area under the receiver operating characteristic curve greater than the average radiologist by an absolute margin of 11.5%, a 2020 analysis found. Another trial estimated it could reduce a second reader’s workload by 88%.

“Through this collaboration we hope to not only alleviate the increasing burdens on radiologists worldwide but also reduce disparities in healthcare across the globe,” Greg Corrado, PhD, head of health AI at Google, said in the announcement.

Nashua, New Hampshire-based iCAD also announced its second quarter earnings results Monday, including an adjusted EBITDA (earnings before interest, taxes, depreciation and amortization) loss of $1.5 million. In a separate announcement, Brown said the plan is to concentrate on countries “where a double-reading workflow is standard practice.”

“With the majority of imaging facilities outside the U.S. still using 2D mammography as the standard of care, this agreement expands and accelerates our ability to serve this market and revolutionize screening for millions of women around the world,” she added.

To read more, go to Radiology Business.

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