‘A big deal’: CMS pilot puts onus on ordering providers to support necessity of radiology services

Imaging industry advocates are praising a new pilot process from CMS that puts the onus on ordering providers to help defend the medical necessity of radiology services.

The Centers for Medicare and Medicaid Services first announced the change last week, which is set to take effect on Dec. 1. It stipulates that Medicare Administrative Contractors should begin requesting any important documents from ordering providers during the review phase to determines whether payment is warranted.

“There are instances in which radiology service providers selected for review are unable to acquire supporting documentation, possibly retained by the treating/ordering practitioner,” the agency said in an Oct. 30 notification to MACs. “CMS is piloting an approach that will enable MACs to receive pertinent documentation from the treating/ordering practitioner during medical review, in an effort to support the necessity and payment for radiology services/items billed to Medicare.”

It may seem like a small change, but members of the field applauded the move on Thursday.

“The American College of Radiology Contractor Advisory Committee Network appreciates CMS issuing this guidance to MACs and treating/ordering providers,” ACR said in a Nov. 5 news update. “This is a big deal and something we have been pushing for years,” it added, quoting an unnamed, longtime representative of the CAC.

ACR noted that Medicare Administrative Contractors possess the ability to automatically deny a claim if there are any uncertainties or ask for additional documentation to determine medical necessity. Under the pilot, they’ll now conduct these third-party reviews by reaching out directly to the physician’s office or inpatient facility that requested any imaging exam, rather than the radiology provider.