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CMS to Reduce Medical Record Review for Docs in Certain APMs

October 13, 2016
by Rajiv Leventhal
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The Centers for Medicare & Medicaid Services (CMS) is announcing an 18-month pilot program to reduce medical record review for physicians practicing in certain advanced alternative payment models (advanced APMs).

This effort from CMS, which the agency’s Acting Administrator Andy Slavitt tweeted, “comes on the eve of MACRA”—referring to the Medicare Access and CHIP Reauthorization Act final rule—aims to reshape the physician experience by reviewing regulations and policies to minimize administrative tasks and seek other input to improve clinician satisfaction. The initiative will be led by senior physicians within CMS who will report to the Office of the Administrator.

The MACRA proposed rule calls for the streamlining of various quality reporting programs into a single framework. It does this by guiding providers down one of two paths—the Merit-Based Incentive Payment System (MIPS) or APMs. Most policy folks expect the overwhelming majority (90 percent or more) of eligible doctors to choose the MIPS path as the two-sided risk models as part of the advanced APM track are very aggressive for many.

Slavitt is appointing Shantanu Agrawal, M.D., to lead the development of this function and implementation, which will cover documentation requirements and existing physician interactions with CMS, among other aspects of provider experiences. To ensure CMS is hearing from physicians on the ground, each of the 10 CMS regional offices will oversee local meetings to take input from physician practices within the next six months and regular meetings thereafter, officials said.

For background, CMS said it “has a statutory duty to protect the Medicare Trust Funds against inappropriate payments, and to take corrective action when they are identified. To accomplish this, CMS uses contractors to review claims and payments for accuracy. Most of these reviews involve only an automated analysis of claims data, but for some claims, the contractor may request records from the provider to compare the medical record to the claim and make a payment decision—this is known as medical review.”

As such, medical review requires physicians to submit medical record documentation to support the claims selected for review. CMS said that certain advanced APMs were identified as a first opportunity for this pilot because participating providers share financial risk with the Medicare program. “Two-sided risk models provide powerful motivation to deliver care in the most efficient manner possible, greatly reducing the risk of improper billing of services,” the agency stated.

The following Advanced APMs will be included in the pilot:

  • Next Generation ACOs,
  • Medicare Shared Savings Program Track 2 and 3 participants
  • Pioneer ACOs
  • Oncology Care Model 2-sided Track participants

The pilot will be comprised of two phases, beginning in early 2017. During the first phase of the program, CMS will direct Medicare administrative contractors (MACs), recovery audit contractors (RACs), and the supplemental medical review contractor to consider as a low-priority for post-payment medical record review claims from providers participating in advanced APMs for beneficiaries aligned to the model. In the second phase, providers in certain Advanced APMs will also be considered as a low-priority for prepayment medical record review by MACs.

“Physicians and their care teams are the most vital resource a patient has. As we implement the Quality Payment Program under MACRA, we cannot do it without making a sustained, long-term commitment to take a holistic view on the demands on the physician and clinician workforce,” said Slavitt. “The new initiative will launch a nationwide effort to work with the clinician community to improve Medicare regulations, policies, and interaction points to address issues and to help get physicians back to the most important thing they do—taking care of patients.”



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