AHIMA Advocates for Streamlined Audits and Coding Review Processes in CMS RFI on Program Integrity

By Sue Bowman, MJ, RHIA, CCS, FAHIMA

In November, AHIMA submitted comments in response a Centers for Medicare and Medicaid Services (CMS) request for information (RFI) on the future of program integrity. According to CMS, program integrity focuses on “paying the right amount, to legitimate providers and suppliers, for covered, reasonable, and necessary services provided to eligible beneficiaries while taking aggressive actions to eliminate fraud and abuse. According to the CMS RFI request, rapid change and growth in Medicare have presented immense challenges and demanded creative solutions from CMS as they strive to “pay it right,” which is a phrase CMS uses to define program integrity.

CMS uses many program integrity tools, such as contractors that conduct prepayment and post-payment review and implement auto-deny edits. However, the design of many of these program integrity methods are rooted in the past. While computer edits automatically review claims before they are paid and data analytics can detect patterns of overuse or other improprieties via post-payment review, fewer than three-tenths of one percent of Medicare fee-for-service (FFS) claims receive any sort of medical record review. When claims are medically reviewed—a process that involves manual review of the patient’s medical record to confirm compliance with Medicare documentation rules—CMS sees a 5 to 1 return on investment when comparing costs to recoveries.

While more reviews by CMS could reduce improper payments, the need for a clinician to personally review patient medical records and determine if claims meet payment requirements is very costly. The level of provider burden associated with medical review is also an important consideration. CMS is looking for new and innovative strategies and technologies, perhaps involving artificial intelligence and/or machine learning, which are more cost-effective and less burdensome to providers, suppliers, and the Medicare program.

The RFI on the future of program integrity is intended to obtain input from stakeholders and experts on innovative methods and tools to elevate its program integrity efforts. CMS wants to make sure that its program integrity tools remain effective not only in the existing FFS world, but also adapt, grow, innovate, and expand to emerging new value-based purchasing systems as well. The agency intends to elevate program integrity, unleash the power of modern private sector innovation, prevent rather than chase fraud, waste, and abuse through smart, proactive measures, and unburden providers and suppliers so they can focus on patient care.

In its comments on this RFI, AHIMA stated that improper payments and noncompliance with payment and coverage rules could be reduced by simplifying the rules and requirements, standardizing them across federal programs, and providing greater transparency regarding payment and coverage policies, rules, and requirements. Differences in local coverage determinations (LCDs) also contribute to the complexity of payment and coverage policies. AHIMA recommended that CMS continue to explore ways to improve consistency across coverage policies, and that the agency consider eliminating LCDs altogether in order to simplify Medicare coverage policies and make it easier for providers to comply with these policies.

Another source of confusion between provider policies and payer requirements is the lack of a single definition for many clinical conditions that are uniformly used by all providers and payers. AHIMA recommended that CMS and its audit contractors allow the use of more than one clinical definition for a medical condition when more than one definition exists that is generally accepted and in widespread use across the US.

It is important for both providers and payers to receive proper education to ensure the accuracy of submitted claims and the claims review process. AHIMA members have indicated that individuals responsible for reviewing the accuracy of Medicare and Medicaid claims do not always understand coding rules and guidelines. Therefore, AHIMA recommended that personnel employed by the Medicare and Medicaid programs, state Medicaid agencies, or contractors of one of these entities (including audit contractors), and who are responsible for reviewing coding accuracy, should be educated on proper coding practice and application of official coding rules and guidelines. AHIMA also suggested that CMS consider requiring that coding reviews be conducted by certified health information management professionals.

In response to a question regarding strategies, tools, or technologies to help CMS better connect ordering physicians, rendering providers, and suppliers with respect to their responsibility to provide proper documentation, AHIMA suggested blockchain technology as one possible approach. The revised certification criteria proposed under the Office of the National Coordinator for Health IT’s “21st Century Cures Act: Interoperability, Information Blocking and the ONC Health IT Certification Program” proposed rule can also facilitate communication between providers by giving patients electronic access to health information from the ordering provider, which can be shared with the rendering provider.

In the RFI, CMS also asked what strategies, tools, or technologies exist to help providers and suppliers become more aware of the necessary documentation requirements earlier in the claim process. AHIMA responded that recovery audit contractors (RACs) should be required to provide sufficient details regarding their findings, which providers can use to improve their coding and billing practices and avoid the same adverse audit findings in the future.