CMS Launches Pilot Medicare Medical Review Program

The Centers for Medicare & Medicaid Services (CMS) has announced an 18-month pilot program to reduce medical record review for certain physicians while continuing to protect program integrity.

Under the program, providers practicing within certain Advanced Alternative Payment Models (Advanced APMs) will be relieved of additional scrutiny under certain Medicare medical review programs, according to a media release from CMS.

CMS 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.

The Importance of Reducing the Requirement of Documentation Submission by Clinicians in the Medicare Program

Medical review serves an important purpose in maintaining the integrity of the Medicare program. It requires physicians to submit medical record documentation to support the claims selected for review. That said, CMS routinely seeks out opportunities to ease the documentation submission requirements and process, as the media release highlighted.

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. Like other Medicare-enrolled providers, those practicing in Advanced APMs are also subject to rigorous program integrity controls, including prescreening against criminal and inappropriate behavior, mandatory data reporting, and additional oversight, which safeguard against fraud and abuse.

How It Works

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.

Phase 1 – Post-payment reviews conducted 1/1/2017 – 6/1/2018. 

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.

RACs and MACs may review claims on a post-payment basis, and are responsible for identifying and correcting improper payments.

The Supplemental Medical Review Contractor (SMRC) conducts nationwide post-payment medical review on certain services and provider specialties selected by CMS, usually because of over-billing concerns identified by the Office of the Inspector General or the Government Accountability Office. Note that these referrals are not for fraud/abuse issues.

Phase 2 – Pre-payment reviews conducted 4/1/2017 – 6/1/2018.

In the second phase, providers in certain Advanced APMs will also be considered as a low-priority for prepayment medical record review by MACs.

  • MACs perform analysis of fee-for-service claim data to identify atypical billing patterns and perform claim review, usually on a pre-payment basis.

Participating Advanced APMs will still be subject to the existing level of oversight from other review programs, including:

  • Zone Program Integrity Contactor reviews
  • Office of the Inspector General and Department of Justice cases
  • Quality reporting
  • Reviews conducted as a result of evidence of abusive billing (gaming or intentionally submitting inaccurate claims)Claims from physicians and hospitals not aligned with the Advanced APM are not included in the pilot.

Claims from durable medical equipment suppliers, home health agencies, and other types of providers are not included in the pilot. Providers participating in the Medical Review Reduction pilot should continue to submit medical records to home health agencies, durable medical equipment suppliers, and others upon request.

During the 18-month pilot, CMS will monitor the progress of the program, and will determine whether to continue or expand it based on results.

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