Why should we care if the vascular lab is accredited and the physician doing the interpretation is qualified? Quite simply, if a patient is sent to the vascular lab and receives a false-positive test, this may expose the patient to additional unnecessary testing or procedures with potential complications. On the other hand, a patient receiving a false-negative test may have a false sense of security, delay in diagnosis, and potentially an adverse clinical event. Unfortunately, this happens too frequently in current clinical practice. A typical example is that of a patient with an asymptomatic cervical bruit referred for a carotid duplex scan. A false-positive scan may lead to another more invasive test, such as a CT or cerebral angiogram. It is less likely but possible that this patient could be subjected to an unnecessary carotid endarterectomy based on this erroneous initial test. On the other hand, if the test is a false negative, and the patient has a critical stenosis, watchful waiting may lead to cerebrovascular symptoms, even a stroke. The sensitive issue about appropriate testing is being debated ad nauseam in the media with regard to screening mammography for women and the ideal age and frequency to be carried out. The American Board of Internal Medicine (ABIM) sponsored an initiative named Choosing Wisely to help patients and laymen understand the appropriateness of tests (www.​choosingwisely.​com).

With the proliferation of vascular labs and mobile units, many payors have begun to require that testing facilities be accredited. According to the IAC website, CMS requirements in most states stipulate that the lab and/or the technologist performing the test need to be credentialed in order to receive full reimbursement. Clearly, this is an important first step to ensure that vascular testing is done properly. The substandard testing in some unaccredited labs should be considered fraud and abuse, and invariably leads to repeat testing in an accredited lab, a waste in precious resources [7]. In response to the perceived overuse of diagnostic imaging, the US congress mandated major payment cuts for all diagnostic modalities in the Deficit Reduction Act of 2006; some tests were cut by 40% [8]. Furthermore, the most recent Healthcare Law passed in the USA in 2015, MACRA (Medicare Access and Children’s Health Insurance Program Reauthorization Act), aims to achieve better care, smarter spending, and healthier people, in part by tying a significant portion of reimbursement to quality (https://​www.​cms.​gov/​Medicare/​Quality-Initiatives-Patient-Assessment-Instruments/​Value-Based-Programs/​MACRA-MIPS-and-APMs/​MACRA-MIPS-and-APMs.​html).