Last month, the Centers for Medicare and Medicaid Services (“CMS”) released a request for information (“RFI”) to obtain input on how the agency can use emerging technologies such as artificial intelligence (“AI”) to ensure proper claims payment and reduce provider burden, as well as how to generally increase efficiency in program integrity activities.
The RFI is organized into the following sections:
- AI Medical Record Review Tools in Medicare Fee-For-Service (“FFS”) – Relates to a number of general questions about the use of AI, including the use of medical record review tools to determine compliance with coverage guidelines, as well as the mechanics of how providers would use those tools, and what are the possible unintended consequences of using such tools. This section also contains specific questions directed to AI Medical Record Review Tool Vendors, and Healthcare Providers and Suppliers.
- Documentation Requirement Repositories – Relates to look-up services and the ability to have all documentation requirements available immediately. CMS questions how to phase in such a process, and if there are consumer-facing smart phone apps that could assist patients and family members in determining what items or services a provider might order, along with the prior authorization process and specific documentation requirements.
- Advanced Technologies for CMS to use in Medicare Advantage and for CMS Contract-Level Risk Adjustment Data Validation (“RADV”) Audits – Relates to improving the process for transferring medical records from Medicare Advantage organizations, as well as how artificial intelligence and machine learning can be used to that end. CMS also queries the feasibility of CMS systems directly retrieving records from providers’ electronic health records (“EHRs”), and if this would decrease the burden on suppliers and providers.
- Provider Enrollment – Relates to how to improve provider enrollment, including how to collect and potentially enhance the provider screening system, so that CMS can examine and validate affiliation information.
- Data Analytics and Data Systems – Relates to data analytic tools and technologies that would help CMS enhance the fraud prevention system (“FPS”), and ensure the compatibility with legacy data systems.
CMS notes that they currently use sophisticated systems, such as the FPS, that use predictive technology to “identify abnormal trends and billing patterns, investigate abnormalities to find the root cause, act quickly to address any potential fraud, and capture fraudulent behavior.” However, CMS believes that the use of additional techniques, such as artificial intelligence and machine learning tools, will lead to “greater savings for taxpayers and allow us to review more claims.”