Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

CMS Launches Provider Engagement, Value-Based Care Initiative

Through a provider engagement program, CMS plans to improve the clinician experience with value-based care and the Medicare program in general.

- CMS recently announced a new provider engagement initiative designed to improve the clinician experience within the Medicare program, especially as value-based care models are developed under the Affordable Care Act and MACRA.

New provider engagement initiative aims to improve value-based care, Medicare through provider feedback, CMS stated

As alternative payment models are implemented, CMS noted that the provider experience has significantly changed to incorporate value-based reimbursement requirements, such as robust quality reporting and enhanced care coordination. Through the provider engagement initiative, the federal agency intends to make the clinician experience better by assessing regulations and policies, reducing administrative burden, and gathering provider feedback.

“Physicians and their care teams are the most vital resource a patient has,” stated Andy Slavitt, CMS Acting Administrator. “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. 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.”

Slavitt selected Shantanu Agrawal, MD, CMS Deputy Administrator and Director, to head the clinician engagement initiative, which is expected to address clinical documentation requirements and existing provider relationships with CMS as well as other provider experience components.

All ten CMS regional offices will also participate in the initiative by conducting local meetings within the next six months to collect provider feedback. The offices will hold regular meetings thereafter and report recommendations to the federal agency’s Administrator in 2017.

“CMS is turning a new page in assessing not only how to reward for quality, but also to reduce administrative hurdles,” added Agrawal. “I look forward to hearing about what steps we can take to make the practice of medicine in Medicare more efficient and rewarding.”

As its first task, the clinician engagement initiative plans to tackle medical record review burdens. In an 18-month pilot program, providers in selected Advanced Alterative Payment Models under MACRA’s proposed Quality Payment Program will not be subjected to as many medical record reviews to justify claims.

CMS currently employs contractors to review Medicare reimbursements and claims for accuracy. Most claims and payments are analyzed through an automated process, but sometimes contractors request medical records to review more complex cases.

The federal agency intends to ease administrative burdens on providers by classifying clinicians in certain Advanced Alternative Payment Models as low-priority for medical record reviews.

The following Advanced Alternative Payment Models will be part of the pilot program:

• Next Generation Accountable Care Organizations (ACOs)

• Medicare Shared Savings Program Track 2 and 3 participants

• Pioneer ACOs

• Oncology Care Model 2-Sided Track participants

CMS selected Advanced Alternative Payment Models as the project’s focus because participating providers will have demonstrated shared financial risk with the Medicare program. Two-sided risk models incentivize providers to make care delivery more efficient and prevent improper medical billing to maximize shared savings payments.

Providers in Advanced Alternative Payment Models would also already operate under strict Medicare program integrity controls, such as criminal and improper behavior prescreening, required data reporting, and additional oversight.

In the first phase of the program, expected to launch in January 2017, Medicare Administrative Contractors, Recovery Audit Contractors, and Supplemental Medical Review Contractors will categorize Advanced APM providers as low-priority for post-payment medical record reviews as long as the payments and claims are associated with beneficiaries aligned with the model.

Under the second phase, scheduled to launch in April 2017, Medicare Administrative Contractors will consider Advanced APM providers as low-priority for pre-payment medical record reviews.

Despite a relaxing of the rules, CMS noted that participating providers will still be held accountable in other Medicare review programs, including Zone Program Integrity Contractor reviews, Office of the Inspector General and Department of Justice cases, quality reporting, and fraudulent medical billing reviews.

However, claims from durable medical equipment, home health agencies, and other providers will not be included in the pilot program. Participating providers should continue to submit medical records as necessary for those claims.

The pilot program is scheduled to end in June 2018, but CMS intends to track the program’s progress to determine if it will continue or expand.

Dig Deeper:

Preparing the Healthcare Revenue Cycle for Value-Based Care

Value-Based Care Transition Begins with Physician Engagement

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