Medicare to Reduce Procedure Volumes


To understand how payers' decisions and policies can affect a company's revenue. To demonstrate this point, the enclosed News Brief summarizes key points for a new Medicare program designed to affect imaging and therapeutic procedure volumes.

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Medicare will soon begin to require all healthcare providers to use a certified clinical decision support system when ordering imaging tests when performed for eight clinical conditions in the physician office, the hospital outpatient and emergency departments, the ambulatory surgical center and the independent diagnostic testing facility. This program has two objectives; to identify outlier ordering healthcare providers, and to reduce volume by eliminating unnecessary and inappropriate imaging tests.

The imaging tests included in the new Medicare program are magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine studies including positron emission tomography (PET). The eight targeted clinical conditions include coronary artery disease (suspected and diagnosed), suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain including suspected rotator cuff injury, cervical or neck pain, and suspected or diagnosed lung cancer.

Therapeutic procedures that have a dependency on these imaging tests may need to examine for downstream impacts on their business models.

While this Medicare program goes into effect on January 1, 2020, financial penalties on healthcare providers for program noncompliance or inappropriate (imaging) ordering patterns are not scheduled to begin until January 1, 2021. There is an expectation this Medicare program could be emulated by commercial payers as well.

Questions related to the imaging program including its certified clinical decision support systems can be directed to Daniel Zimmerman


Rowinski Group, LLC is a reimbursement and healthcare payer data analytics consultancy for the medical device and digital health technology companies. Rowinski Group is based in Silicon Valley and works with companies, located throughout the world, who are publicly traded, privately held including those funded by government grants.

Rowinski Group has two core service offerings; securing codes and reimbursement on behalf of our client companies and deploying healthcare payer data analytics to solve complex business issues such as responding to questions from the FDA or determining the geographic placement of a U.S. based sales force.

2019 V 10.3

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