ROOT Act
- Bill Number
- H.R. 5737
- Origin Chamber
- House
- Congress
- 119th Congress, Session 1
- Policy Area
- Health
- Status
- Introduced
- Latest Action
- 2025-10-10: Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
- Last Updated
- 2025-12-09T18:18:07Z
AI-Generated Summary
Purpose of the Legislation
The Radiology Outpatient Ordering Transmission Act (ROOT Act), H.R. 5737, aims to update rules under Medicare (title XVIII of the Social Security Act) for collecting and using data on "appropriate use criteria" (AUC)—evidence-based guidelines to ensure imaging services, like X-rays or MRIs, are medically necessary. The goal is to simplify reporting, delay stricter enforcement, add exemptions, and focus on monitoring compliance rather than immediate penalties, while improving data for future policy decisions.
Key Provisions
- Data Reporting by Clinical Decision Support Mechanisms (CDSMs): Starting January 1, 2026, CDSMs (software tools that help doctors choose appropriate imaging based on AUC) must report specific data to the Secretary of Health and Human Services (HHS), including details on orders, consultations, and other relevant information in a format specified by HHS.
- Consultation Requirements: Ordering professionals (e.g., doctors requesting imaging) must consult a qualified CDSM for most advanced outpatient imaging services paid by Medicare, but this is delayed until January 1, 2026, with HHS setting the exact rules.
- Exemptions from Consultation: Certain cases are exempt, including:
- Imaging ordered as part of clinical trials.
- Orders from small practices (15 or fewer ordering professionals) or rural health professional shortage areas.
- Preventive or screening services like mammograms, lung cancer CT scans, or colon CT scans; HHS can add more.
- Claim Submission Rules: Furnishing professionals (e.g., those performing the imaging) must include the ordering professional's unique identifier (National Provider Identifier, or NPI) on Medicare claims starting January 1, 2026, if they differ.
- Compliance Monitoring: HHS will annually identify "low compliant" ordering professionals—those with a compliance rate below a threshold set by HHS—based on data from CDSMs. Compliance rate is calculated as the percentage of imaging orders where a CDSM was consulted (excluding exempt orders).
- Studies and Reports: By January 1, 2031, and every five years after, HHS must study compliance rates, imaging utilization, and propose improvements (e.g., prior authorization for low compliers or payment adjustments). It also suggests alternative thresholds for low compliance.
- Endorsement Process: HHS must generally follow existing rules (from 2023) for endorsing AUC and CDSMs, prioritizing input from medical specialty societies.
Significant Changes to Existing Law
- Delays full enforcement of CDSM consultation from earlier dates (like 2017 pilots) to January 1, 2026, replacing prior requirements with flexible HHS guidance.
- Shifts from "outlier" ordering professionals (high-volume non-compliers) to "low compliant" ones based on percentage of non-consulted orders, using CDSM-reported data.
- Removes immediate prior authorization penalties (struck from prior law) and replaces them with ongoing studies rather than automatic sanctions.
- Adds new reporting mandates for CDSMs and NPI inclusion on claims; expands exemptions to protect small/rural providers and screenings.
- Introduces HHS guidance on how CDSMs report data to support monitoring and future adjustments.
Potential Impacts
- On Government Agencies: The Centers for Medicare & Medicaid Services (CMS, part of HHS) will need to update systems for data collection, annual compliance determinations, and periodic reports to Congress, potentially increasing administrative workload but improving data-driven policymaking on imaging overuse.
- On Citizens: Medicare beneficiaries may see more appropriate imaging orders, reducing unnecessary tests and costs (e.g., lower copays or deductibles), but exemptions ensure access in rural or small practices without delays.
- On International Relations: No direct impact, as this is a domestic Medicare policy.
- Overall, it could reduce imaging overuse (estimated to cost billions annually) while easing burdens on providers, leading to better resource allocation in healthcare.
Main Stakeholders Affected
- Ordering Professionals: Doctors or clinicians requesting imaging; they must use CDSMs for most orders but benefit from exemptions and no immediate penalties.
- Furnishing Professionals: Radiologists or imaging facilities; required to add NPIs to claims, affecting billing processes.
- Medicare Beneficiaries: Patients receiving imaging services; potential for fewer unnecessary procedures and lower program costs passed indirectly to premiums/taxes.
- CMS/HHS: Oversees implementation, data analysis, and reporting; gains better tools for monitoring.
- Specialty Societies: Medical groups (e.g., radiology associations) whose endorsed guidelines influence AUC and CDSMs.
- CDSM Developers: Companies providing consultation software; must enhance reporting features to comply.
Notable Legal, Constitutional, or Political Implications
- Legal: Builds on the 2014 Protecting Access to Medicare Act's AUC framework without creating new mandates; emphasizes administrative flexibility (e.g., HHS rulemaking) to avoid legal challenges over vague enforcement. No private right of action for individuals, keeping disputes administrative.
- Constitutional: No apparent issues; aligns with Congress's spending power over Medicare and does not infringe on free speech or due process, as compliance is tied to payment eligibility, not coercion.
- Political: Promotes bipartisan healthcare efficiency (introduced by Republicans but affects broad Medicare reforms); delays penalties may appeal to provider lobbies, while studies on prior authorization could spark debates on government overreach in medicine. Could influence future cost-control efforts amid rising Medicare spending.
This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.
Sponsor
Rep. Harshbarger, Diana [R-TN-1]
Cosponsors (1)
Recent Actions
- 2025-10-10: Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
- 2025-10-10: Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
- 2025-10-10: Introduced in House
- 2025-10-10: Introduced in House
Bill Versions
- Radiology Outpatient Ordering Transmission Act — issued 2025-10-10 — PDF (11 pages)