Overview of the Protecting Access to Medicare Act by Erin Lane of The Advisory Board Company and Bob Cooke of NDSC.

1. Imaging Clinical Decision Support:
The Medicare Mandate
Prepared for National Decision Support Company
Imaging Performance Partnership
Erin Lane
Senior Analyst
Imaging Performance Partnership,
Advisory Board
lanee@advisory.com
March 9, 2017

2. ©2017 Advisory Board • All Rights Reserved • advisory.com
2
membership renewal rate
among U.S. hospitals
of U.S. News and World Report
“Honor Roll” hospitals are members
96% 100%
health care member
organizations
4,400+
CEO and COO
relationships
9,500+
Through the breadth of our network and
the depth of our expertise, we forge and
find the best practices that
• Help our members set course
• Power the technologies needed
to accelerate progress
• Provide the foundation for
consulting partnerships
that transform
organizations
Start with
best practices
STRATEGY
Helping CEOs, chief marketing officers, and chief strategy officers
chart course and grow their businesses.
CARE DELIVERY
Helping chief medical officers, medical group executives,
network executives, and clinical leaders to shape networks, engage
physicians, manage medical group performance, implement care
pathways, accelerate population health efforts, and more.
OPERATIONS
Helping CFOs and COOs reboot their approach to profitability.
Then hardwire those insights into your organization
with research, technology, and consulting

3. ©2017 Advisory Board • All Rights Reserved • advisory.com
3
CDS Comprised of Two Distinct Parts
Source: Imaging Performance Partnership interviews and analysis.
IT Tool
Electronic platform that
makes guidelines accessible
Appropriate Use Criteria
Clinical guidelines
Clinical
Decision
Support +=

4. ©2017 Advisory Board • All Rights Reserved • advisory.com
4
Medicare Legislation Mandates CDS1 for Imaging
Provider Requirements and Legislative Recap
Source: “Protecting Access to Medicare Act of 2014” Congress of the
United States of America, April 1, 2014; Imaging Performance
Partnership interviews and analysis.
1) Clinical decision support.
2) Only Medicare fee-for-service.
3) National provider identification number.
Legislation in Brief:
Protecting Access to Medicare Act (2014)
Providers must indicate that the ordering clinician used an approved
decision support mechanism to consult appropriate use criteria for all
applicable outpatient advanced imaging exams for Medicare fee-for-
service beneficiaries
Ordering Provider Requirements
• Consult appropriate use criteria
(AUC) via CDS for Medicare
beneficiaries2
• For outpatient advanced imaging
exam (CT, MR, PET, nuclear
medicine) orders
Furnishing Provider Requirements
Submit documentation of ordering
provider use on Medicare claim:
• CDS mechanism consulted
• Adherence to AUC
• NPI3 of ordering professional
Imaging order

5. ©2017 Advisory Board • All Rights Reserved • advisory.com
5
A Brief History and What’s to Come
Provider Consultation and Documentation Required by January 1, 2018
Source: Centers for Medicare and Medicaid Services, CMS.gov;
Imaging Performance Partnership interviews and analysis.
1) Protecting Access to Medicare Act.
Regulatory Timeline for Clinical Decision Support
April 2014
PAMA1 signed into law,
requiring provider use of AUC
via CDS for advanced imaging
November 2015
MPFS2 CY 2016 final rule
established appropriate use
criteria approval process
November 2016
MPFS CY 2017 final rule established CDS
mechanism requirements and approval
process, clinical priority areas
January 1, 2018
Ordering providers must consult AUC through
qualified CDS; to receive payment, furnishing
must submit claims-based documentation
January 1, 2020
Ordering providers identified
as outliers, may be required
to obtain preauthorization
Today

6. ©2017 Advisory Board • All Rights Reserved • advisory.com
6
For the First Time, More Knowns Than Unknowns
Medicare AUC Program Beginning to Taking Shape
Source: Centers for Medicare and Medicaid Services, CMS.gov;
Imaging Performance Partnership interviews and analysis.
CDS Components Yet to Be Determined
AUC approval process: Provider-
led entities may qualify to create,
modify guidelines
Vendor (mechanism) approval
process: Requirements for
mechanisms set; first list of
approved mechanisms to be
released by July 2017
Furnishing provider penalties
• Imaging claims without documentation
will be denied, meaning no
reimbursement for professional or
technical components
• But will CMS instead implement a
penalty for the first year?
Claims-based reporting
• CMS must create new claims form to
enable proper documentation
Outlier provider status: How will
CMS calculate outliers? How long
with the outlier status remain?
Provider deadline: January 1, 2018
for ordering and furnishing providers
CDS Components Finalized More Clarification Needed

7. ©2017 Advisory Board • All Rights Reserved • advisory.com
7
Qualified Provider-Led Entities to Create, Modify AUC
All Providers Use Criteria Developed by PLEs1 to Comply With Mandate
Source: Centers for Medicare and Medicaid Services, CMS.gov;
Imaging Performance Partnership interviews and analysis.
1) Provider-Led Entities.
Rather than approving individual criteria, CMS
approves groups, or “provider-led entities” to
create, modify, endorse AUC
Qualified PLEs As of July, 2016
American College of Cardiology Foundation
American College of Radiology
Brigham and Women’s Physician Organization
CDI Quality Institute
Intermountain Healthcare
Massachusetts General Hospital, Radiology
National Comprehensive Care Network
Society for Nuclear Medicine and Molecular
Imaging
University of California Medical Campuses
University of Washington Physicians
Weill Cornell Medical Physicians Organization
To comply with the mandate, ordering
providers must use AUC from qualified PLEs
CMS will release list of newly approved PLEs
by June 30 of every year, so the number of
PLEs will grow over time
Appropriate User Criteria Basics

8. ©2017 Advisory Board • All Rights Reserved • advisory.com
8
Becoming a Qualified PLE
Six Requirements, New Applications Accepted Annually
Source: Centers for Medicare and Medicaid Services, CMS.gov;
Imaging Performance Partnership interviews and analysis.
Provider-Led Entities Qualification Requirements
Finalized Definition for Provider-Led Entity
“An organization comprised primarily of providers or
practitioners who, either within the organization or outside
of the organization, predominantly provide direct patient
care.…all AUC developed or endorsed by that provider-
led entity will be considered to be specified AUC.”
Related Deadlines
Follow robust
evidentiary-review
process for criteria
Publically disclose
conflicts of interest
Publically post all AUCs
and evidence on website
Grade criteria in terms
of strength of evidence
Publically outline AUC
development process
AUC development
process led by
multidisciplinary team(s)
Jan 1: Applications due to CMS
June 30: CMS will release list of qualified
provider-led entities on website

9. ©2017 Advisory Board • All Rights Reserved • advisory.com
9
In the Waiting Game for CDS Mechanisms
Requirements Finalized and Deadline Passed but Awaiting Approved List
Source: Centers for Medicare and Medicaid Services, CMS.gov;
Imaging Performance Partnership interviews and analysis.
Providers must use qualified
CDSM to comply with mandate
Sample CDSM Requirements
Incorporates reasonable scope of AUC
Incorporates AUC from more than one qPLE
Makes AUC, support documents available
Determines appropriateness of imaging
exams
Documents provider use with unique identifier
Ability to update AUC in reasonable
timeframe
Stores necessary information for six years
Provides aggregate feedback annually to
provider
Compiles with privacy laws requirements
CDS Mechanism Basics
Mechanisms must adhere to
full set of requirements
CDSM Dates for Providers to Know
March 1: Application deadline for 2017 approval
June 30: CMS to publish list of approved
CDSMs

10. ©2017 Advisory Board • All Rights Reserved • advisory.com
10
Two Levels of CDSM Approval
The Provider’s Guide to CDSM Approval
Source: Centers for Medicare and Medicaid Services, CMS.gov;
Imaging Performance Partnership interviews and analysis.
Level 1:
Preliminary Approval
Level 2:
Full Approval
Approval
Definition
CDSM does not meet all
requirements, but has a clear plan
in place to meet all requirements by
January 1, 2018
CDSM meets all requirements
on date of application: March 1,
2017
Does this
CDSM meet all
requirements?
• No
• Submitted clear plan to meet all
requirements by January 1, 2018
Yes
Will providers
using this
CDSM on
January 1, 2018
comply with the
mandate?
• No
• Preliminarily approved CDSMs
become fully approved after
demonstrating adherence to all
requirements
• CDSMs that cannot meet all
requirements by January 1, 2018
required to notify providers
Yes

11. ©2017 Advisory Board • All Rights Reserved • advisory.com
11
Priority Clinical Areas Used to Determine Outliers
Targeted Clinical Groupings to Evolve, Expand With Time
Source: Centers for Medicare and Medicaid Services, CMS.gov;
Imaging Performance Partnership interviews and analysis.
1) Not included in proposed rule.
2) Traumatic and non-traumatic.
3) Primary or metastatic, suspected or diagnosed.
Finalized Priority Clinical Areas
1 Coronary artery disease1
2 Suspected pulmonary embolism1
3 Headache2
4 Hip pain1
5 Low back pain
6 Shoulder pain1
7 Cancer of the lung3
8 Cervical or neck pain
CMS to increase number,
scope of areas annually
Priority Clinical Area Used to
Identify Referrer Outliers
CMS will analyze imaging utilization and
CDS compliance within priority clinical
areas (PCAs) to identify outlier referrers
by 2020 and set scope requirements for
AUC in CDSMs
CMS selected diagnostic
groups with highest
associated advanced
imaging volumes

12. ©2017 Advisory Board • All Rights Reserved • advisory.com
12
Holding Providers Accountable for Appropriateness
Process Penalties for Ordering Providers, Financial for Furnishing
Source: Centers for Medicare and Medicaid Services, CMS.gov;
Imaging Performance Partnership interviews and analysis.
1) As required by the law, but CMS has not yet finalized.
Ordering Provider Requirements
• Consult appropriate use criteria (AUC)
via CDS for Medicare beneficiaries2
• For outpatient advanced imaging
exam (CT, MR, PET, nuclear
medicine) orders
Furnishing Provider Requirements
Submit documentation of ordering provider
use on Medicare claim:
• CDS mechanism consulted
• Adherence to AUC
• NPI3 of ordering professional
Imaging order
Penalty for Noncompliance1 Penalty for Noncompliance1
Classified as an outlier, required
to obtain preauthorization for
Medicare patients
Claims denied and reimbursement
withheld; applies to both professional
and technical components

13. ©2017 Advisory Board • All Rights Reserved • advisory.com
13
QUESTIONS
Erin Lane
Senior Analyst
Imaging Performance Partnership
The Advisory Board Company
lanee@advisory.com

14. ©2017 Advisory Board • All Rights Reserved • advisory.com
14
Best Practices for CDS Implementation
Advisory Board Resources to Support Your CDS Strategy
Source: Imaging Performance Partnership interviews and analysis.
FOR ALL RESOURCES
on this topic, visit advisory.com/ipp/CDS
Toolkit for Successfully Implementing
Imaging Clinical Decision Support
Comprehensive set of tools that map to tactics
for thoughtful and effective implementation of
imaging CDS
Playbook for Implementing Clinical
Decision Support
The imaging leaders guide to successful
CDS implementation, including case studies
from successful organizations

15. Imaging Clinical Decision Support: The Medicare Mandate
Thank You!
Send Additional Questions to LaneE@Advisory.com
Erin Lane
Senior Analyst
Imaging Performance Partnership
The Advisory Board Company
lanee@advisory.com

16. ©2017 Advisory Board • All Rights Reserved • advisory.com
IMPORTANT: Please read the following.
Advisory Board has prepared this report for the
exclusive use of its members. Each member
acknowledges and agrees that this report and
the information contained herein (collectively,
the “Report”) are confidential and proprietary
to Advisory Board. By accepting delivery of this
Report, each member agrees to abide by the
terms as stated herein, including the following:
1. Advisory Board owns all right, title, and
interest in and to this Report. Except as
stated herein, no right, license, permission,
or interest of any kind in this Report is
intended to be given, transferred to, or
acquired by a member. Each member is
authorized to use this Report only to the
extent expressly authorized herein.
2. Each member shall not sell, license,
republish, or post online or otherwise this
Report, in part or in whole. Each member
shall not disseminate or permit the use of,
and shall take reasonable precautions to
prevent such dissemination or use of, this
Report by (a) any of its employees and
agents (except as stated below), or
(b) any third party.
3. Each member may make this Report
available solely to those of its employees
and agents who (a) are registered for the
workshop or membership program of
which this Report is a part, (b) require
access to this Report in order to learn from
the information described herein, and
(c) agree not to disclose this Report to
other employees or agents or any third
party. Each member shall use, and shall
ensure that its employees and agents use,
this Report for its internal use only. Each
member may make a limited number of
copies, solely as adequate for use by its
employees and agents in accordance with
the terms herein.
4. Each member shall not remove from this
Report any confidential markings, copyright
notices, and/or other similar indicia herein.
5. Each member is responsible for any
breach of its obligations as stated herein
by any of its employees or agents.
6. If a member is unwilling to abide by any
of the foregoing obligations, then such
member shall promptly return this Report
and all copies thereof to Advisory Board.