A Review of Rule-Making

The Commission on Economics has provided rule-making comments for decades.

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One of the core activities of the Commission on Economics is engagement with CMS on Medicare payment policy. This occurs on multiple fronts, but it largely centers on the regulatory, rule-making process. CMS is required to share updates to its payment systems through annual proposed rules, a process which allows for a public comment period before a final rule is released. Any member of the public may submit comments, and the ACR does so on behalf of our members and the radiology profession. Proposed and final rules are released for the Medicare Physician Fee Schedule (MPFS), the Quality Payment Program (QPP), the Hospital Outpatient Prospective Payment System, and the Inpatient Prospective Payment System, among others. The Commission reviews each of these documents. This task is not a small one. Every year, CMS releases around 10,000 pages of rule-making documents. For 2020, the MPFS and QPP Notice of Proposed Rule-Making (NPRM) document is more than 1,700 pages long.

The Medicare rule-making process follows the same general timeline each year. CMS makes the rule-making documents available to the public via the Federal Register for the following year. The NPRM is released around the beginning of July, with comments due in September. A final rule is released around Nov. 1, with those policies going into effect the following Jan. 1.

Our Commission is quite experienced in this process — having provided rule-making comments for decades. In this column, I describe how our Commission undertakes its review.

Step 1: Notify the Membership Immediately

Our first task is to review the rules within hours of their release, allowing us to have a summary available to our members that same evening. The proverbial “on call” applies here, since we do not know exactly when the rule will drop. To that end, we must have the appropriate resources in place. This initial review requires that ACR staff examine sections related to their respective areas of expertise, with the assistance of our physician volunteers.

Step 2: Conduct a Deeper Dive

Once the initial dust settles, a deeper review starts. We engage many of the same expert volunteers and staff, but the process expands to our broader economics Committees. For instance, RVS Update Committee valuations are reviewed by our Committee on Reimbursement, and the Quality Payment Program is reviewed by our Committee on MACRA. As we review the NPRM, we tap into resources beyond our Commission. The ACR works with several healthcare consulting firms. Their perspectives, longitudinal experience, and database availability are necessary to support our comments and responses.

Step 3: Collaborate With Each Other

We collaborate internally. Many issues overlap with other Commissions within the ACR. For instance, the QPP overlaps considerably with the Commission on Quality and Safety, where measure development occurs. The Commission on Informatics is engaged in matters related to promoting interoperability. And the Commission on Government Relations has a say in how regulations are changed by previous and evolving legislation, both at the federal and the state levels.

We also collaborate externally. We have many issues in common with physicians and healthcare professionals within the house of radiology and outside it. For example, policies that affect our IR, nuclear medicine, and radiation oncology members are also relevant to their respective sub-specialty societies. Likewise, we value the input of our colleagues on the business side of radiology, such as the RBMA. And, of course, the broader house of medicine is important, such as the AMA and state medical societies. Here we may share common issues, such as those related to matters like surprise billing or scope of practice.

Step 4: Combine Collective Efforts

The last step involves bringing everything together for final review, both internally and with the collaborative groups I have mentioned. We share our letter early in hopes that our positions will be included in other societies’ comment letters.

Most of what I describe occurs over a period of eight to 10 weeks. Even after we submit our comments, the job is not done. Often, ACR representatives will meet with CMS during the comment period, or shortly thereafter, to further state their positions. The final product, at the most basic level, is a rule-making letter intended to influence policy. The letter is also a public statement of our position(s). Of equal importance, the document provides a radiology-specific summary of evolving payment policy, where the ACR stands and how our members’ practices may be affected.


By Ezequiel Silva III, MD, FACR, Chair

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