Provider Led Entity
In June of 2016, the Centers for Medicare and Medicaid (CMS) named the RAYUS Quality Institute as one of the qualified Provider Led Entities (PLE) to assist in fulfilling the ambitious mandate in the 2014 federal Protecting Access to Medicare Act. The mandate will better assure that all Medicare patients receive the right imaging test at the right time.
The Institute’s governing board of physicians is devoted to developing appropriate use criteria (AUC) based on clinical evidence that is also of practical use for community-based physicians.
Below, please find answers to questions you may have about our Provider Led Entity.
Multidisciplinary Committee
The RAYUS Quality Institute serves as the provider-led entity (PLE) and the Institute’s PLE Multidisciplinary Committee serves as the multidisciplinary team. Certain functions and responsibilities are performed by contract with third parties.
2022 Multidisciplinary Committee Members:
- Thomas J. Gilbert, MD, MPP – Chair
- Robert Liddell, MD – Vice Chair
- Lawrence Cowsill, DO, FACOI
- Michael Ulissey, MD, FACR
- Vincent Mathews, MD, FACR
- Steven R. Pollei, MD
- Kellie Schenk, MD
- Michael Finch, PhD
- Paul Allegra, MD
- Erik Rockswold, MHA, MA
Under formal resolution by the RAYUS Quality Institute’s Council of Medical Directors, the PLE Multidisciplinary Committee is a free-standing committee within the Institute, created for the purpose of administering all of the functions of the multidisciplinary team as set forth in the federal regulations. This structure provides for the necessary transparency, autonomy and accountability in carrying out this responsibility. The PLE Multidisciplinary Committee has the following characteristics:
- Members have been appointed by the Executive Committee from among the Members of the Council and employees of the Medical Practices that participate in the Institute, or from affiliated entities where there has been a demonstrated commitment to high quality, community-based health care services as well as for their independent professional judgment. These members serve indefinite terms, subject to removal for good cause and upon two-thirds vote of the Executive Committee.
- Statistical Analysis support is provided by Michael Finch, PhD.
- The PLE Multidisciplinary Committee’s determinations will not be subject to modification or rejection by The RAYUS Quality Institute, its Members, its Executive Committee or any other party.
AUC Library
The Multidisciplinary Committee is the initial and final authority on all Appropriate Use Criteria. For each clinical topic area, the Multidisciplinary Committee convenes subject expert panels, consisting of the individuals listed below, to provide an additional level of review and advice on current evidence- and consensus-based practices.
With the Institute’s commitment to prioritize areas of most use to community-based physicians while also adhering to the spirit and intent of the PAMA law and implementation regulations, the following Appropriate Use Criteria (AUC) areas have been developed:
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Priority Clinical Area: Lung Cancer
- Appropriate Use Criteria
- Panel experts:
- Tom Gilbert, MD, MPP: RAYUS Chief Clinical Officer and PLE Chair
- Michael McNeeley, MD – body radiologist at Medical Scanning Consultants, and medical director of hospital solutions at RAYUS Radiology
- Smitha Menon, MD – Associate Professor of Hematology and Medical Oncology at Medical College of Wisconsin
- David Thorson, MD – family medicine physician with Entira Family Clinics and member of Fairview Physician Associates Network
- Systematic Lit Review Process
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Priority Clinical Area: Coronary Artery Disease
- Appropriate Use Criteria (Updated September 2022)
- Panel experts:
- Lawrence Cowsill, DO, FACOI: Internist, and Senior Medical Director of McLaren Physician Partners
- Luba Frank, MD: Professor and Chief of Diagnostic Radiology, Cardiothoracic Imaging at Medical College of Wisconsin
- Tom Gilbert, MD, MPP: RAYUS Chief Clinical Officer and PLE Chair
- John Lesser, MD, FSCCT: Director of Cardiovascular CT and MRI at Minneapolis Heart Institute/Abbott Northwestern Hospital
- Peter Mason, MD: Associate Professor of Cardiovascular Medicine, Vascular Surgery, and Radiology at Medical College of Wisconsin
- Systematic Literature Review Process
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Priority Clinical Area: Low Back Pain
- Appropriate Use Criteria (Updated December 2022)
- Panel experts:
- Bruce Bartie, DO, Orthopedic Surgeon; Twin Cities Orthopedics, MN
- Thomas Gilbert, MD, MPP, RAYUS Chief Clinical Officer and PLE Chair
- David Thorson, MD, Family Practice/Sports Medicine; Entira Family Clinics, MN
- Marjorie Wang, MD, MPH, Professor of Neurosurgery; Medical College of WI
- Systematic Literature Review Process
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Priority Clinical Area: Cervical and/or Thoracic Back Pain
- Appropriate Use Criteria (Cervical Spine – Updated December 2022)
- Appropriate Use Criteria (Thoracic Spine Pain – Updated December 2022)
- Panel experts:
- Bruce Bartie, DO, Orthopedic Surgeon; Twin Cities Orthopedics, MN
- Thomas Gilbert, MD, MPP, RAYUS Chief Clinical Officer and PLE Chair
- David Thorson, MD, Family Practice/Sports Medicine; Entira Family Clinics, MN
- Marjorie Wang, MD, MPH, Professor of Neurosurgery; Medical College of WI
- Systematic Literature Review Process
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Priority Clinical Area: Shoulder Pain
- Appropriate Use Criteria (Updated September 2021)
- Panel Experts:
- Lawrence Cowsill, DO, Internist; McLaren Healthcare, MI
- Hollis Fritts, MD, MSK Radiologist; RAYUS, MN
- Thomas Gilbert, MD, MPP, RAYUS Chief Clinical Officer and PLE Chair
- Steven Grindel, MD, Professor of Orthopedic Surgery; Medical College of WI
- Rob Liddell, MD, PLE Vice Chair and MSK Radiologist; RAYUS, WA
- Systematic Literature Review Process
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Priority Clinical Area: Suspected Pulmonary Embolism
- Appropriate Use Criteria (Updated November 2021)
- Panel Experts:
- Sean Caples, DO, MS, Pulmonologist & Critical Care Specialist; Mayo Clinic, MN
- Ryan Clay, MD, Pulmonary & Critical Care Medicine Fellow; Mayo Clinic, MN
- Gaurav Dagar, MD, Pulmonologist & Critical Care Specialist; Medical College of WI
- Thomas Gilbert, MD, MPP, RAYUS Chief Clinical Officer and PLE Chair
- Richard Gray, MD, Emergency Medicine Physician; Hennepin County Medical Center, MN
- Systematic Literature Review Process
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Priority Clinical Area: Headache
- Appropriate Use Criteria (Updated November 2021)
- Panel Experts:
- Frederick Freitag, DO, Associate Professor of Neurology; Medical College of WI
- Thomas Gilbert, MD,MPP, RAYUS Chief Clinical Officer and PLE Chair
- Bruce Penner, RN, Rural Health Quality Consultant, MN
- Steven Pollei, MD, National Section Leader for Neuroradiology; RAYUS, WA
- Sonja Potrebic, MD, PhD, Southern CA Permanente Medical Group Co-assistant Chief of Neurology and American Academy of Neurology Fellow
- Systematic Literature Review Process
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Priority Clinical Area: Hip Pain
- Appropriate Use Criteria (Updated February 2022)
- Panel Experts:
- Thomas Gilbert, MD,MPP, RAYUS Chief Clinical Officer and PLE Chair
- Rob Liddell, MD, PLE Vice Chair and MSK Radiologist; RAYUS, WA
- Peter Moley, MD, Physiatrist at Hospital for Special Surgery; NYC
- Brad Moser, MD, Twin Cities Orthopedics Primary Care/Sports Medicine Physician; MN
- Joseph Schwab, MD, Assistant Professor of Orthopedic Surgery; Medical College of WI
- Systematic Literature Review Process
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Abdomen/Pelvic Imaging
- Appropriate Use Criteria (Updated February 2021)
- Panel Experts:
- Paul Allegra, MD, Cuyuna Regional Medical Center Emergency Department Director; MN
- Todd Cunningham, MD, National Section Leader for Body Imaging, RAYUS; MN
- Thomas Gilbert, MD,MPP, RAYUS Chief Clinical Officer and PLE Chair
- Andrew Kastenmeier, MD, Assistant Professor of General Surgery; Medical College of WI
- Systematic Literature Review Process
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Renal, Adrenal, and Urinary Tract
- Appropriate Use Criteria (Updated July 2020)
- Panel Experts:
- Robert Kanterman, MD, Body and Interventional Radiologist, RAYUS; MO
- Paul Knechtges, MD, Associate Professor of Radiology; Medical College of WI
- Thomas Gilbert, MD,MPP, RAYUS Chief Clinical Officer and PLE Chair
- Aaron Milbank, MD, President, Metro Urology; MN
- Lynne Ogawa, MD, Family Physician, Westside Community Health Services; MN
- Anthony Polcari, MD, Metro Urology; MN
- Ramapriya Sinnakirouchenan, MD, Assistant Professor of Medicine; Medical College of WI
- Systematic Literature Review Process
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Knee Pain
- Appropriate Use Criteria (Updated February 2022)
- Panel Experts:
- Thomas Gilbert, MD,MPP, RAYUS Chief Clinical Officer and PLE Chair
- Tony Jeanmenne, MD, RAYUS MSK Radiologist; MN
- Rob Liddell, MD, PLE Vice Chair and MSK Radiologist; RAYUS, WA
- Brandon Messerli, DO, Evergreen Health Sport and Spine Care Physiatrist; WA
- Edward Nelsen-Freund, MD, Assistant Professor of Orthopedic Surgery; Medical College of WI
- David Strobel, MD, Pipe Trades Services Minnesota Family Physician; MN
- Systematic Literature Review Process
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Stroke/CVA
- Appropriate Use Criteria (Updated April 2020)
- Panel Experts:
- Paul Allegra, MD, Cuyuna Regional Medical Center Emergency Department Director; MN
- Lawrence Cowsill, DO, Internist; McLaren Healthcare, MI
- Thomas Gilbert, MD, MPP, RAYUS Chief Clinical Officer and PLE Chair
- John Lynch, MD, Associate Professor and Division Chief, Stroke, Neurointervention and Critical Care; Medical College of WI
- Kishan Yalavarthi, MD, Neuroradiologist; RAYUS, St. Louis
- Systematic Literature Review Process
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Rhinosinusitis
- Appropriate Use Criteria (Updated February 2021)
- Panel Experts:
- Eric Becken, MD, Otolaryngologist, Midwest Ear, Nose & Throat; MN
- Thomas Gilbert, MD, MPP, RAYUS Chief Clinical Officer and PLE Chair
- Blake Johnson, MD, FACR, RAYUS Medical Director and Director of Neuroimaging; MN
- Vincent Mathews, MD, FACR, Department of Radiology Chair; Medical College of WI
- David Poetker, MD, Associate Professor of Otolaryngology; Medical College of WI
- Carol Stark, MD, Family Physician, Entira Family Clinics; MN
- Systematic Literature Review Process
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Multiple Sclerosis
- Appropriate Use Criteria (Updated December 2020)
- Panel Experts:
- Staley Brod, MD, Professor of Neurology and Division Chief of MS/Neuroimmunology; Medical College of WI
- Thomas Gilbert, MD, MPP, RAYUS Chief Clinical Officer and PLE Chair
- Susan Minette, DO, Neurologist, Noran Neurological Clinic; MN
- Murray Solomon, MD, National Neuroradiology Section Leader; RAYUS, Los Gatos, CA
- David Strobel, MD, Pipe Trades Services Minnesota Family Physician; MN
- Systematic Literature Review Process
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Neurocognitive Disorders
- Appropriate Use Criteria (Updated April 2020)
- Panel Experts:
- Mohit Agarwal, MD, Assistant Professor of Radiology; Medical College of WI
- Lawrence Cowsill, DO, Internist; McLaren Healthcare, MI
- Malgorzata Franczak, MD, Professor of Neurology; Medical College of WI
- Thomas Gilbert, MD, MPP, RAYUS Chief Clinical Officer and PLE Chair
- Brad Hostetter, MD, RAYUS Council of Medical Directors Chair and Neuroradiologist; IN
- Susan Minette, DO, Neurologist, Noran Neurological Clinic; MN
- Systematic Literature Review Process
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Cough/Dyspnea
- Appropriate Use Criteria (Updated September 2021)
- Panel Experts:
- Ryan Clay, MD, Pulmonologist & Critical Care Specialist; Kaiser Permanente, Portland, OR
- Gaurav Dagar, MD, Pulmonologist & Critical Care Specialist; Medical College of WI
- Thomas Gilbert, MD, MPP, RAYUS Chief Clinical Officer and PLE Chair
- Richard Gray, MD, Emergency Medicine Physician; Hennepin County Medical Center, MN
- Michael McNeeley, MD, Body Imaging Radiologist; RAYUS, MN
- Systematic Literature Review Process
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Ankle/Hind Foot Pain
- Appropriate Use Criteria (Updated September 2022)
- Panel Experts:
- Tom Gilbert, MD, MPP, RAYUS Chief Clinical Officer and PLE Chair
- Brian Law, MD, FAAOS, Orthopedic Surgeon; Medical College of WI
- Rob Liddell, MD, PLE Vice Chair and MSK Radiologist; WA
- Nancy Kadel, MD, Orthopedic Surgeon; Seattle Spine & Sports Medicine; WA
- Brad Moser, MD, Twin Cities Orthopedics Primary Care/Sports Medicine Physician; MN
- Systematic Literature Review Process
AUC Development & Evidentiary Review Process:
The RAYUS Quality Institute PLE’s evidentiary review process adheres to the following steps in developing appropriate use criteria (AUC).
The RAYUS Quality Institute PLE’s Multidisciplinary Committee (MDC) is ultimately responsible to assess the quality of evidence for the AUC topic areas. The MDC convenes expert panels to further inform its decision making. The MDC also has arranged for some literature assessments to be initially begun by AIM Specialty Health.
- For each subject area, our process includes an initial set of investigational questions, which we develop using the Patient/Problem, Interventions, Comparison, Outcome (PICO) framework. Those initial questions are reviewed, modified, and approved by the MDC.
- For certain topics, the MDC has arranged for AIM Specialty Health to undertake a literature search and grading process using the AGREE II instrument [a tool to assess the methodological rigor and transparency in which a guideline is developed] and the GRADE approach [a widely adopted, transparent framework for grading the quality of evidence]. For some topics, this literature search and grading process is completed by the RAYUS Quality Institute PLE.
CDI QI PLE Strength of a Body of Evidence - The results of the literature search and grading process are reviewed and our PLE statistician may modify the result. Our PLE Chair and support staff then develop a draft AUC narrative that synopsizes the relevant evidence and recommendations.
CDI QI PLE Strength of Recommendation - The expert panel then meets to review the draft AUC, and to discuss and modify as appropriate. The federal regulations require that “to the extent feasible” our AUC should be evidence-based; the regulations also require that we identify key points in each particular criterion as being evidence-based or consensus-based. We consider consensus statements developed by medical specialty societies and similar organizations.
- After the expert panel meets, the modified draft AUC is presented to the MDC for further review and discussion. Following approval by the MDC, the final AUC are published on the RAYUS Quality Institute PLE website, together with all authoring and supporting documentation.
- The AUC and supporting documentation for clinical priority areas, as defined by CMS, are reviewed and updated on an annual basis.
RAYUS Quality Institute and AIM Specialty Health Collaboration
The RAYUS Quality Institute and RAYUS have a decades-long history of pursuing public policy and medical practice solutions which add value to our patients and partners. The use of clinical decision support tools documents that the right test is done at the right time – and that is a good thing for ALL patients, not just those covered by the federal Medicare program. Therefore, the RAYUS Quality Institute continues to strive to build bridges which address the challenges of prior authorization for treating clinicians and their patients who are not covered by Medicare.
The RAYUS Quality Institute and AIM Specialty Health are building one of these bridges; it has a wide and high span.
- The Institute is undertaking its AUC development work in collaboration with AIM Specialty Health (AIM).
- AIM is a leading specialty benefits management company. For the past 30 years, AIM has developed appropriateness criteria for advanced radiology, which are integrated into a review system available online for providers to use through a secure online portal. AIM is accredited by both NCQA and URAC and meets the standards for clinical criteria development established by each of these organizations.
- AIM has a proven internal process for the development of evidence-based criteria. A primary element of that established process, systematic literature review, is used to support the work of the Institute. For the purposes of this collaboration, AIM provides the Institute PLE Multidisciplinary Committee with the literature search results for evaluation in the sole discretion of the PLE Multidisciplinary Committee. The subsequent development and modification of AUC is undertaken exclusively by the Institute’s PLE Multidisciplinary Committee, and this committee does not endorse any guidelines created specifically by AIM. The autonomous responsibility for developing AUC is firmly vested in the PLE Multidisciplinary Committee.
Conflicts of Interest
The RAYUS Quality Institute and our PLE have a robust policy to address the issue of actual or perceived conflicts of interest. The policy was reviewed and approved by the Federal government as part of our qualification process. Any director, principal officer or member of the PLE Committee, or any person who participates in the Committee’s efforts to develop or modify AUC is subject to this policy. Persons subject to the policy must disclose (and update) any ownership, investment, compensation or other financial interest with a broad range of stakeholders and are subject to exclusion from participation in the AUC development process based on certain criteria. The policy is implemented and overseen by the PLE Administrator.
- To read our Conflicts of Interest Policy, click here
- To view our Conflicts of Interest reporting form, click here