CMS Announces Reduced Medical Review Pilot Program for Providers Aligned with Certain Advanced APMs

On October 13, 2016, the Centers for Medicare & Medicaid Services (CMS) announced an 18-month pilot program to reduce the burden of medical record review of clinicians participating in certain Advanced Alternative Payment Models (APMs). CMS uses contractors to review payments and claims for accuracy. Despite the administrative burden on both the agency and providers to conduct these reviews, CMS views them as necessary to meet its statutory duty to protect the Medicare Trust Funds.


Program Overview


The following Advanced APMs will be included in the pilot:

  • Next Generation
  • Medicare Shared Savings Program (Track 2 and 3)
  • Pioneer ACOs
  • Oncology Care Model – 2 sided Track

Phase 1 – Post-payment Reviews Conducted 1/1/2017-6/1/2018

Claims for beneficiaries aligned to the identified Advanced APMs will be considered as low-priority for post-payment medical reviews by Medicare Administrative Contractors (MACs), Recovery Audit Contractors and the Supplemental Review Contractor.

Phase 2 – Pre-payment Reviews Conducted 4/1/2017-6/1/2018

In the second phase, providers in identified Advanced APMs will be considered as a low priority for pre-payment medical review by MACs.

These providers will still be subject to the existing level of oversight from other review programs including: Zone Program Integrity Contractor reviews, Office of the Inspector General and Department of Justice cases, quality reporting, and reviews conducted as a result of abusive billing.

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.

More information on the pilot program is available here.


Other Elements of the Initiative

CMS indicates that through this program they are aiming to improve the clinician experience with the Medicare program. CMS presents this pilot program as similar to other delivery system reform efforts that have been initiated through the Affordable Care Act and Medicare Access and CHIP Reauthorization Act (MACRA). Advanced APMs were seen as an ideal area to initiate this program because participating clinicians share financial risk with the Medicare program and are viewed as being motivated to deliver care in the most efficient manner as possible.

This pilot program is the first step in a larger initiative to reshape and improve the physician experience with Medicare program. Acting Administrator Andy Slavitt appointed Dr. Shantanu Agrawal to lead the initiative. CMS will hold local meetings within the next six months at regional offices to gather input from physicians and are planning on instituting regular meetings thereafter. These local meetings will result in a report with targeted recommendations to the CMS Administrator in 2017.

For many physicians the administrative burden and real financial costs of audits, denials and appeals can be significant. This announcement could be welcomed by providers as well as a desire to expand the pilot beyond the selected Advanced APMs.


Click here to access the McDermottPlus MACRA Resource Center.