In order to improve "clinician engagement" and minimize administrative burdens, CMS has announced an 18-month pilot program to reduce medical review audits for participants in selected Advanced Alternative Payment Models (Advanced APMs), beginning January 1, 2017. Under this program, CMS will direct Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and the Supplemental Medical Review Contractor to make claims submitted by certain Advanced APMs providers a "low priority for medical record reviews." CMS notes that automated reviews (which make up the majority of MAC and RAC reviews), reviews by other entities (e.g., Zone Program Integrity Contractors, the Office of Inspector General, and Department of Justice) and quality reviews will continue unchanged.
Advanced APMs included in this pilot program are: Next Generation Accountable Care Organizations (ACOs); Medicare Shared Savings Program Track 2 and Track 3 participants; Pioneer ACOs; and Oncology Care Model 2-sided Track participants. CMS selected these Advanced APMs because participating clinicians share financial risk with the Medicare program, providing "powerful motivation to deliver care in the most efficient manner possible, greatly reducing the risk of improper billing of services which exists under the Medicare fee-for-service program." CMS has posted frequently-asked questions about the pilot program here.
This article is presented for informational purposes only and is not intended to constitute legal advice.