This week, ASCRS responded to two CMS requests for information (RFI) on modifying program integrity activities designed to identify and prevent waste, fraud, and abuse in the Medicare and Medicaid programs. In one RFI, CMS asks for feedback on the potential to incorporate AI technology into program integrity. ASCRS strongly opposed this concept in our response due to the lack of any available technology that could accurately identify and analyze the broad diversity of medical documentation. Furthermore, we are concerned that AI technology could inaccurately identify specialists and sub-specialists, who tend to treat the sickest patients, as outliers in billing practices and subject them to unwarranted audits. Finally, we objected to CMS’ suggestion that AI technologies could be integrated with clinician EHRs due to the additional expense that practices would likely incur, along with disruption to the clinical practice to implement an additional complex technology.
In our response to the second RFI, which focuses on updating program integrity to reflect the move to value-based payment, we thanked CMS for recognizing the need to modify its processes. Specifically, we recommended that CMS tailor its program integrity activities based on the characteristics of the particular model, rather than develop one-size-fits all solutions. These processes should be developed alongside the models themselves and target areas that the developers consider could be open to waste, fraud, or abuse. In addition, we recommended that CMS take a measured approach to audits of the Quality Payment Program (QPP), allowing ample time for physicians to respond to audits and take corrective action before applying penalties. Finally, we recommended CMS modify prior authorization to focus on evidence-based guidelines and exclude physicians who provide treatment within those guidelines. We will keep you updated.