Protecting Access to Medicare Act (PAMA)

Provider Brief     January 2020

Premier Health is taking the next step to comply with CMS regulations which are part of PAMA, the Protecting Access to Medicare Act. These regulations are aimed at increasing the rate of appropriate advanced diagnostic imaging services provided to Medicare patients and were written by medical providers and societies. Penalties for noncompliance begin in 2021. 

Providers need to be aware of the following as these regulations take effect:

  • CMS requires that all orders for advanced diagnostic imaging be evaluated by a clinical decision support mechanism (CDSM) to assess the reasonability and medical necessity for the test.
  • Premier Health is in the process of switching from ACR Select to the Stanson-Premier CDSM, also accessed through Epic. Because user feedback on ACR Select has not been positive, a transition to Stanson-Premier has been initiated.
  • Stanson-Premier will use information in the chart, including anything “entered” in the reason for exam field, to determine suitability for the order. When you order a test in Epic, you may not need to take any additional steps — or you may be guided through additional questions as needed. For assistance, as always, you can consult Technical Education or the ESS (Epic Support Specialist) team.
  • The new rules apply to eight clinical areas and apply to all included advanced imaging tests, regardless of who places the order.
  • Since 2020 is the first year of operations for the new regulations, there are no penalties for failure to comply.
  • Beginning in 2021, failure to comply means CMS will not pay the hospital or the radiologist for the test. Ultimately, providers whose ordering patterns are considered outliers will be subject to prior authorization.

Premier Health’s goal is to make this transition as effortless as possible.

Questions or concerns may be directed to Walter Reiling, MD, Chief Medical Informatics Officer (937) 499-5127(937) 499-5127 or [email protected].

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