CMS Ramps Up Payment Scrutiny
Federal payers are increasing their oversight on billing and compliance, with major implications for imaging providers. CMS is rolling out a new real-time program integrity initiative and is being backed by Medicare Advantage insurers in its push to curb chart review payments. This reflects a broader trend toward tougher documentation requirements and site-of-service accuracy.
The CMS CRUSH initiative signals a significant operational shift, moving from a "pay and chase" model to real-time fraud detection and earlier intervention in the payment process. For providers, this means incomplete or ambiguous documentation is more likely to be flagged earlier in the claim lifecycle. This analytics-driven oversight is designed to spot patterns like unusual growth in specific codes or variances from billing benchmarks across all federal healthcare programs. On the Medicare Advantage front, CMS is targeting diagnoses from "unlinked" chart reviews—those conducted outside of a clinical encounter—which are not used in traditional Medicare. A proposed rule aims to eliminate these from risk score calculations starting in 2027, a move that could decrease MA payments by over $7 billion. This follows findings that chart reviews contributed to an estimated $24 billion in additional MA payments in 2023. The broader market is seeing a continued shift of imaging services to outpatient settings, which now account for roughly 40% of all radiology volume. While hospitals still handle the majority of imaging nationwide, significant regional variations exist; for example, in Baltimore, 91% of mammography occurs outside of hospitals. Projections show outpatient advanced imaging, particularly PET, ultrasound, and CT, will grow by nearly 14% over the next decade. In response, many health systems are pursuing a "systemness" strategy by acquiring or partnering with freestanding imaging centers to capture this growth. This trend is driven by both patient demand for more convenient and affordable care options and the need for health systems to build a presence in the expanding ambulatory care market. This shift is happening amidst a persistent radiologist shortage, which increases operational backlogs and burnout. To cope, providers are turning to workflow optimization tools and artificial intelligence to improve efficiency. AI algorithms are increasingly used for triage, prioritizing urgent cases, and flagging abnormalities, allowing radiologists to focus on complex interpretations. The FDA has cleared hundreds of AI-enabled tools for medical imaging, with vendors like GE Healthcare, Siemens Healthineers, and Philips leading the market. By mid-2025, the FDA had approved approximately 873 radiology AI algorithms, making medical imaging the largest target for AI among all medical specialties. AI integration has shown tangible results, such as in stroke care, where AI-powered alerts have been shown to get patients to treatment about 66 minutes faster. Payment policies are also evolving under the Hospital Outpatient Prospective Payment System (HOPPS). The 2026 final rule included a 2.6% increase to the conversion factor and higher-than-expected payments for services like 3D printing and contrast-enhanced ultrasound. However, it also included a 57% reimbursement reduction for certain SPECT scans, frustrating nuclear cardiology advocates.
