CMS Pilot Makes It A Responsibility On Ordering Service Providers To Support The Need of Radiology Services

Advocates of the healthcare imaging industry are increasingly praising an innovative pilot process from the CMS, which puts the responsibility on ordering service providers to defend the medical urgency of these radiology services.

The Centers for Medicare and Medicaid Services announced these changes, which were all set to be effective on December 1, 2020. It underlines that the Medicare Administrative Contractors should start requesting all important and necessary papers from ordering the providers in the review phase and determine whether such payment is truly warranted.

In a notification given to the MACs on October 30, 2020, the agency said, “There are several instances in which the radiology services chosen for a review were unable to acquire the supporting documentation, perhaps retained by ordering/treating practitioner. CMS is piloting a specific approach to enable MACs to receive such pertinent documentation from the ordering/treating practitioner during the medical review, in their effort to support the need and payment for radiology items/services billed to the Medicare.”

Although it may seem to be a very insignificant change, members of this field applauded this move.

On November 5, 2020, the ARC said in a news update, “The American College of Radiology Contractor Advisory Committee Network appreciates the issuance of this guidance from the CMS to the MACs and ordering/treating providers. This means a big deal and it is something that we were pushing for several years.”

ARC also noted that the Medicare Administrative Contractors had the ability to deny any claim automatically if there were any uncertainties involved or even ask for further documentation to decide the medical necessity. Under this pilot, they would now conduct some third-party reviews. To do that, they have to reach out directly to the respective physician’s office or an inpatient facility, which requested for such an imaging exam, instead of the radiology provider.

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