CMS alert highlights Medicare fraud scheme involving phishing fax requests
The Centers for Medicare & Medicaid Services (CMS) published an alert on fraud schemes that are increasingly targeting Medicare providers that involve bad actors impersonating CMS and sending phishing fax requests for medical records and documentation, falsely claiming to be part of a Medicare audit.
Phishing is an example of social engineering that attempts to trick someone into giving out sensitive information. Email phishing attacks are still a common occurrence, but the AMA is hearing about more fraudulent fax requests being sent out to medical practices by bad actors.
CMS emphasized that it does not initiate audits by requesting medical records via fax. The AMA urges physicians and practices to take steps to protect their data. If physicians receive a suspicious request, they should not respond. CMS encourages physicians to work with their Medical Review Contractor if they receive a questionable or suspected fraudulent request to confirm if it is real.
2023 QPP report shows APM participation increase, little MVP uptake, and more trends
CMS recently released the 2023 Quality Payment Program (QPP) Experience Report (PDF) and accompanying public use file, which provide insights into key metrics for physicians who participated in either the Merit-based Incentive Payment System (MIPS) or alternative payment models (APMs), including specialty trends.
Notably, between 2022 and 2023, there was a 21% increase in the number of clinicians who were qualifying APM participants (463,669 compared to 384,105), which made them exempt from MIPS and eligible for a 3.5% lump-sum bonus in 2025. As a result of more clinicians being exempt from MIPS, there was a 13% drop in MIPS-eligible clinicians from 2022 to 2023. The mean MIPS final score was 83.18 points, and the median was 85.49 points. Both exceeded the performance threshold of 75 points, the final score needed to avoid a negative payment adjustment. As a result, approximately 80% of MIPS eligible clinicians earned a positive payment adjustment of up to 2.15% and less than 15% received a penalty, with just over 2% receiving the maximum penalty of –9%.
The AMA continues to point out that MIPS is expensive and burdensome to report and disconnected from quality of care, and as a result, solo practitioners, small practices, and rural practices are disproportionately more likely to receive a penalty, including the maximum penalty. The AMA is strongly urging (PDF) the Trump administration to dramatically overhaul MIPS to more closely align MIPS with clinical practice and level the playing field for small and rural practices.
New for 2023, physicians could report MIPS via a MIPS Value Pathway (MVP), which includes a subset of measures and activities based on a specialty or medical condition. In 2023, physicians were able to voluntarily register and report on 12 MVPs as an individual, group, or subgroup of a multi-specialty practice.
Out of 541,421 MIPS eligible clinicians in 2023, 6,790 MIPS ECs reported and were scored on MVPs, only 101 of which reported and were scored as subgroup. The Anesthesia MVP was the most highly registered and reported MVP, while the Episodic Neurological Conditions MVP was the least registered and reported MVP.
Many more physicians registered and reported on MVPs than were scored on them because more than 98% also reported traditional MIPS. Under current scoring rules, when physicians submit multiple scores, CMS uses the highest for the final score that adjusts Medicare payment, and physicians generally had higher scores from traditional MIPS. CMS published a MIPS Value Pathways (MVP) Reporting Supplement, which includes comparison information about physicians’ scores in MVPs versus traditional MIPS. CMS has previously indicated it intends to make MVPs mandatory in future reporting years, which the AMA and many national medical specialties have strongly opposed (PDF).
CMS announces Wasteful and Inappropriate Service Reduction (WISeR) Model
CMS recently announced the Wasteful and Inappropriate Service Reduction (WISeR) Model, a new Innovation Center demonstration aimed at reducing Medicare spending on services deemed “low-value” or unnecessary. Beginning in 2026, in selected regions, CMS will use artificial intelligence and machine learning, as well as clinical reviewers to perform pre-payment prior authorization reviews for targeted services, such as electrical nerve stimulator implants, skin and tissue substitutes, and knee arthroscopy procedures. Providers in the selected regions will have the choice to either submit a prior authorization request for these services or instead have claims undergo a pre-payment review. The demonstration will run for six performance years, with participating technology vendors being incentivized to help identify and deny wasteful claims before payment is made. While CMS anticipates savings and more efficient uses of Medicare dollars, the model represents a significant shift in how care is reviewed in Traditional Medicare.
The AMA has serious concerns about WISeR’s potential to increase physicians’ administrative burdens, delay patient care, and shift profit incentives to third-party vendors focused on denials rather than high-quality care. The AMA is especially concerned that this model could further expand prior authorization requirements into Traditional Medicare, by setting a precedent for mandatory programs in the future. The AMA has consistently advocated for clear transparency, fair review standards, real-time processing, and strong protections for both physicians and patients. The AMA is preparing a formal comment letter to CMS and CMMI to share concerns and advocate for improvements that safeguard access to care, reduce unnecessary practice burdens, and urge that all elements of the model (and any future iterations) be truly voluntary.
Updates to the Medicare Advantage audits
CMS recently announced significant updates to its Risk Adjustment Data Validation (RADV) audit process for Medicare Advantage (MA) plans, aimed at strengthening oversight of MA payments to ensure accurate reflections of enrollees’ health status. Under the updated RADV framework, CMS will now audit all eligible MA contracts (approximately 550) annually. Additionally, CMS aims to increase the number of records audited per plan from 35 to up to 200 per year. CMS has also committed to completing all outstanding audits for payment years 2018-2024 by early 2026. To fulfill these goals, CMS will utilize enhanced technologies and will also increase its team of medical coders from 40 to approximately 2,000 by September 2025.
The AMA supports efforts to strengthen the integrity of the MA program and reduce improper payments. However, there are concerns about the potential downstream administrative burden placed on physicians. Through these updates, providers are likely to experience increased medical records requests, tighter deadlines for data correction, and potentially heightened demands from MA plans and vendors for repayment. The AMA encourages physicians to track any new audit-related workload challenges, particularly around responding to records requests or coordinating with MA plans under compressed timelines. If you experience any new challenges related to increased RADV audit activity, the AMA encourages you to share your feedback with us to ensure we properly represent your concerns with the administration.
More articles in this issue
- July 11, 2025: Advocacy Update spotlight on budget reconciliation bill
- July 11, 2025: State Advocacy Update
