Upcoming changes to Medicare will require the use of evidence-based guidelines that are designed to ensure that patients receive appropriate tests and treatments for their conditions and avoid unnecessary care, but the changes could lead to a higher number of denied claims by insurance companies and might spark acts of bad faith.
Medicare Changes and Benefits
Beginning July 1, 2018, physicians will be asked to voluntarily use clinically supported software to document certain criteria for outpatient medical imaging orders. The period from 2018 to 2020 is intended to be used for the industry to get used to the new system and software, and mandatory usage will begin in 2020. To ensure full reimbursement for diagnostic imaging services for Medicare and Medicaid patients, software must be certified by the Centers for Medicare and Medicaid Services (CMS). A number of outpatient imaging scans will be impacted by new guidelines. By making this Medicare change, CMS wants to ensure that expensive advanced imaging procedures are appropriate for the patient’s condition. CMS hopes that this will help to reduce unnecessary imaging scans and overall healthcare costs in the future.
Due to inadequate staffing in physicians’ offices and slow decisions by insurance companies, the current prior authorization process takes time. New Medicare regulations are likely to increase approval times. In a 2016 Medical Association survey of 1,000 physicians, it showed that 20 percent of patients waited an average of three to five days for prior approvals for medical treatments, and six percent waited more than five business days. When physicians were surveyed, 90 percent reported that the prior approval process delayed patient access to necessary care.
Beginning in 2020, billing for medical imaging that does not have the new required software documentation will be denied by CMS. Software vendors were required to submit certification applications to CMS by March 1, 2017, and a formal list of certified vendors became available to medical facilities on July 1, 2017. Thousands of hospitals who perform diagnostic imaging procedures have purchased new software systems, but many systems have yet to be installed. Hospital officials and physicians are concerned that the short time frame to get the list of certified software vendors and the slow start to get imaging systems installed may prompt many bad faith insurance claims and medical billing denials for Medicare and Medicaid patients across the country.