New initiative from CMS to reduce medical record review for clinicians participating in certain Advanced Alternative Payment Models


As part of  Affordable Care Act and Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) reforms, the Centers for Medicare & Medicaid Services (CMS) recently announced an 18-month pilot program to reduce medical record review for certain physicians. 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.

The Advanced APMs included in the pilot are:

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

The pilot will be comprised of two phases, beginning in early 2017.

Phase 1

Phase 1 will apply to post-payment reviews conducted from 1/1/2017 – 6/1/2018.  During this phase of the program, CMS will direct Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) [1] and the Supplemental Medical Review Contractor (SMRC) [2] to consider claims from providers participating in Advanced APMs as a low priority for post-payment medical record review. This would apply to beneficiaries aligned to the model.

Phase 2

Phase 2 will apply to pre-payment reviews conducted from 4/1/2017 – 6/1/2018. In this phase of the program, providers in certain Advanced APMs will also be considered as a low priority for prepayment medical record review by MACs.

CMS indicated that 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 

In addition, claims from durable medical equipment suppliers, home health agencies and other types of providers are not included in the pilot, and 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.

After the results of the pilot are analyzed, CMS will consider expansion along various dimensions, including additional Advanced APMs, specialties and provider types.

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

[2] 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.

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