Medicare Proposes to Shift PAMA from Stick to Carrot

Good news for Radiologists and Medicare Patients…

Medicare Proposes Shift of PAMA AUC from Stick to Carrot

Time for Radiologists and Imaging Centers to Respond

The Centers for Medicare and Medicaid today, July 13, 2017, released their memo: Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2018 .

This is a great time for every radiologist, clinic, hospital and health system to respond to what I call the most “bizarre” payment scheme I’ve seen in my lifetime.

If you are not familiar with the Protecting Access to Medical Act of 2014 (PAMA), I recommend you watch my short video on YouTube.

Video Presentation on Understanding PAMA and Appropriate Use Criteria. July 13, 2017 update.Not only is CMS proposed the delay of PAMA from January 1, 2018 to 1/1/2019, they are hoping to remove the first year penalties and instead leverage the MIPS program under Medicare’s Quality Payment Program (QPP under MACRA). This gives early physician adopters the opportunity to use it as Clinical Practice Improvement activity.

That should be good news to radiologists who were looking for payment denials in 2018 due to AUC requirements.

Why I called this the most “bizarre” payment scheme:

If you aren’t up to date on PAMA and the AUC, watch the video above.  It is a law with good intentions, but a crazy implementation paradigm:

  • We will make physicians (primary care physicians and specialists) ordering advanced diagnostic images (MRI, CT PET scans) run every order request through clinical decision support (CDS) algorithms to make sure the provider selected the best imaging modality for the patient.
    • What a great idea.  We have experts define the imaging Best Test for every situation. We then require that the order for the test provides proof that these “appropriate use criteria” (AUC) were met.
      • Good because we want to do the right test, the first time, to reducing cost, waste and unnecessary radiation exposure.
      • Bad, because the ordering physician has only downside…
  • But then there are consequences of not following this path:
    • If there is no AUC, and the imaging study is performed, don’t expect Medicare to pay the radiologist.
    • Or perhaps the patient shows up for the test and there is no AUC.  The imaging center, desiring to not go bankrupt, should attempt to get a new, valid order with AUC from the ordering physician (remember the radiologist cannot order the studies they read.). This will obviously cause delays in performing the test, delays in getting the results of the study and overall patient dissatisfaction.

And then there has been the spin…

CMS has tried to spin this silly concept to say, “There will be a free service for the ordering physicians to use online services to determine if their patients meet the AUC for this advanced diagnostic studies.

Of course without integration to your EMR, there is nothing free about disrupting your workflow to leave your EMR, log on to a “free service”, reenter the indication and pertinent clinical information in that service to run the CDS, and then transcribe the resulting documentation back into your EMR order.

And the ordering physician, as originally designed, got NOTHING financially for this added cost, lost productivity and patient dissatisfaction.

The Proposed Change is Heading in the Right Direction

We are need to voice our approval to CMS:

YES, we want to delay this a year to January 1, 2019 and not deny timely imaging for our patients and put our radiologists out of business,

YES, let’s harmonize to the QPP and make this a Clinical Practice Improvement Activity under the Merit-based Incentive Payment System (MIPS).  It makes sense to REWARD our PCPs and specialists to do the right thing up front rather than PENALIZE our nation’s radiologists.

Patients will benefit greatly if we all support this CMS proposal with our voice and emails.  You can learn more at

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