Bill aims to restore appropriate use criteria for imaging

A new bill aims to revamp Medicare's imaging oversight process and revive the appropriate use criteria, or AUC program, which CMS indefinitely paused in 2024. Supporters of the bill say that implementation of the AUC program could reduce unnecessary imaging and increase patient safety, resulting in cost savings to Medicare and its beneficiaries.

U.S. Senators Catherine Cortez Masto (D-Nev.) and Marsha Blackburn (R-Tenn.) introduced the bipartisan bill, called the Radiology Outpatient Ordering Transmission (ROOT) Act.

The ROOT Act seeks to amend the Protecting Access to Medicare Act (PAMA), which established the AUC program in 2014. The AUC program was originally set to be implemented by January 2017, but years of challenges with integrating the AUC into existing systems led CMS to rescind the program for reevaluation effective Jan. 1, 2024.

In its original form, the AUC program required practitioners to consult a qualified clinical decision support mechanism (CDSM) whenever they ordered an advanced diagnostic imaging service for a Medicare beneficiary.

"The CDSM provides a determination of whether the order adheres to AUC, or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition)," CMS stated.

"Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization."

The ROOT Act aims to change this process by removing the real-time claims reporting, instead requiring providers to attest that they reviewed the AUC at the point of care. The legislation would also require CMS to conduct retrospective audits based on compliance data to enhance provider education and ensure compliance.

"When the right imaging is used at the right time, it can lead to better health outcomes and reduce costs for patients and the health care system," Cortez Masto said in an accompanying press release. 

"This commonsense, bipartisan legislation supports evidence-based care and reduces unnecessary scans, saving Medicare billions of dollars while ensuring safer, more personalized care."

Specifically, legislators estimated that the ROOT Act would result in a $2.2 billion reduction in federal spending from fiscal year 2025 to fiscal year 2034, as well as $1.6 billion in savings for Medicare beneficiaries over the same period, due to reduced cost-sharing.

The American College of Radiology (ACR) voiced its support for the ROOT Act and urged Congress to pass the bill to promote value-based care and reduce Medicare spending devoted to low-value imaging.

"If the ROOT Act is not passed, AUC program benefits, including reduced unwarranted imaging, increased patient safety, more patient-focused care, and significant savings to Medicare beneficiaries and the Medicare system will remain unrealized," the ACR stated.

Jill McKeon has covered healthcare cybersecurity and privacy news since 2021.