ACR Reveals Prior Authorization Overburdens Radiologists to Congress

TL/DR –

The American College of Radiology (ACR) has proposed a new appropriate use criteria program for imaging for Medicare beneficiaries as an alternative to prior authorization. The program would reduce low-value imaging exams, lessen radiologist burden, and save Medicare roughly $700 million a year. To address insurer utilization management, legislation is being proposed that would require Medicare Advantage plans to gain approval from the Centers for Medicare and Medicaid Services (CMS) before imposing prior authorization on physicians in successful accountable care organizations.

ACR Criticizes Health Plan Prior Authorization Decisions

The American College of Radiology (ACR) has criticized “black box” decision-making by nonphysician health plan employees in prior authorization. The ACR argues this often prioritizes health plan profits over patient care.

Appropriate Use Criteria Program as an Alternative

ACR proposes the shelved Appropriate Use Criteria (AUC) program as an alternative. This would require referrals to consult a decision aid before ordering advanced imaging for Medicare beneficiaries. They believe this would reduce low-value imaging exams, ease the burden on radiologists, and save Medicare $700 million annually.

ACR Suggests Legislative Changes for AUC Implementation

The ACR has recommended changes to the Senate Finance Committee for implementing the AUC program. They urged the swift adoption of the revised legislative text for CMS implementation. They believe these changes would decrease unnecessary utilization and copayment costs while providing a better utilization management tool than prior authorization processes.

Concerns Over Insurer Utilization Management

The Committee on the Budget leaders echoed ACR’s worries about insurer utilization management. They termed prior authorization practices as a “scourge for patients,” criticizing their cumbersome and confusing nature.

Proposed Legislation to Address Prior Authorization

Sen. Sheldon Whitehouse has proposed that Medicare Advantage plans must get CMS approval before imposing prior authorization on physicians practicing in successful accountable care organizations. His legislation would also task CMS with identifying the worst prior authorization practices in Medicare Advantage and setting common standards for these requirements.

Hope for Actions to Ease PA Challenges

Sen. Chuck Grassley expressed optimism that recent actions at CMS would mitigate prior authorization challenges. He also supported enhancing transparency of prior authorization activities.

Both Senators’ testimonies and a recording of the May 8 hearing can be found here. More details can be found in ACR’s news update.

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