CDS, AUC, PAMA, and Patients over Paperwork. One-year CDS with no penalties. Education or enforcement?

The Centre for Medicare and Medicaid Services (CMS) released PAMA (Protecting Access to Medicare Act), according to which ordering providers are now required to consult AUC (Appropriate User Criteria) CDS (Clinical Decision Support) tool while ordering advanced imaging and diagnostic equipment for patients of Medicare. American College of Radiology (ACR) appreciated this announcement, as a result of which ordering providers will no longer need to follow AUC recommendations and 2020 has maximum chances of becoming an academic year without any reimbursement penalties.

Earlier, providers had to follow (PA) Prior Authorization programs which consumed a lot of time, as a result of which patients used to get delayed diagnosis and treatment, and this even took precedence over the medical expertise of a physician. PA programs cost a lot and their operation was done in a non-transparent manner to a great extent. Once the physicians get used to the new CDS process, the number of outliers is expected to decrease significantly and provide transparency. ACR has shown its complete support towards this Patients over Paperwork rule, which is expected to reduce costs and administrative burdens on the physicians.

CMS is an advocacy and non-partisan educational organization that is dedicated to ensuring fair access to quality healthcare for all, especially the elderly patients and those with disabilities. Based on these, here are a few recommendations to follow:

Exchange of Data

If determination and maintenance of dual-eligible programs are concerned, regular exchange of data would be needed among CMS, SSA and Medicail agencies. Any error or delay in this exchange can delay the receival of benefits, and also give a reason to people who may drop from a program that they are eligible for. According to CMS, now all states are required to be a part of MMA data exchange every day. This move is expected to accelerate the automatic enrollment of beneficiaries into the programs they are eligible for. Because of the delays, many patients are not able to afford prescriptions adhere to the beneficiary laws. Daily submission of data will distribute the workload over the state staff so that any errors can be fixed quickly and any new beneficiaries can be added to receive the benefits in no time. That is why it becomes even more important to move towards daily data transmission as soon as possible.

Elimination of Limits on Assets

A large number of Medicare beneficiaries who have limited income resources are not allowed to get enrolled in the MSP, because there are stringent eligibility conditions that they have to follow not only in terms of income but also regarding the assets they may have. Low-income beneficiaries are heavily penalized for keeping savings for emergency expenses and retirement, due to which they are forced to spend a large part of their assets. A large number of beneficiaries even feel discouraged from even applying for enrollment. Many of them find it challenging to collect information about all their assets, and some are just afraid of going through such extensive paperwork. All this burden is even more challenging for people who are already ill, elderly or disabled. Due to this, many patients with limited income still find it difficult to become eligible for this assistance. Eliminating the need for such extensive paperwork and asset test will make the application process simpler for such patients, thereby reducing their administrative burden and costs. With PAMA, patients will now be able to apply for Medicare more quickly with minimal asset tests.

Access to DME (Durable Medical Equipment)

The PAMA announced by CMS is expected to be highly successful in addressing misalignment of payments in Medicare, due to which a large number of DME are denied or delayed in the healthcare industry. With this new approach, states will be able to adopt strategies that can be beneficial for access to DME. However, DME needs to be authorized for access to eligible beneficiaries.

Modification in Overpayment Recovery

Rate of Overpayment Recovery requires CMS to work with SSA to reduce the need for unnecessary demands, as a result of which overpayments will be automatically reduced, and patients will get relief from overpayment recovery rates. The recommendation from CMS will also include a letter that will inform the beneficiary about the overpayment. The appeals and exceptions processes are time-consuming for pharmacists, beneficiaries as well as physicians, and often causes delays in receiving necessary equipment and medications. Now, individuals who are denied access to the required equipment will be able to file an appeal in a quick and easy manner.

All in all, Patients over Paperwork or PAMA announced by CMS is definitely going to be educated rather than being enforcement. At sepStream®, we are dedicated to studying all the announcements being made by the authorities, and accessing them to find out their pros and cons. With up-to-date knowledge and access to the database, we can make you an informed customer or physician in all aspects.