APCM Compliance & Audit Checklist for ACOs

Ensure every beneficiary assigned to the ACO has documented consent for APCM services within the integrated EHR system.

Cross-reference APCM enrollment with the ACO’s quarterly CMS assignment list to prevent billing for non-attributed lives.

Clearly document that the patient was informed of potential 20% coinsurance unless waived by specific ACO model rules.

Provide patients with clear instructions on how to access their care team after hours, a core requirement for APCM compliance.

Explicitly state in the medical record that the patient was informed they can revoke APCM services at any time.

Develop a structured care plan for each APCM patient addressing physical, mental, and psychosocial health needs.

Review and update the care plan at least every 90 days or upon any significant change in the patient's health status.

Use AI logs to capture every minute of care coordination, phone triage, and remote monitoring for non-face-to-face time.

Document all medication reviews and reconciliations, focusing on polypharmacy risks common in senior ACO populations.

Use structured data fields to record SDOH barriers that impact chronic disease management and ACO quality scores.

Ensure APCM activities directly support measures like HbA1c control, blood pressure management, and fall risk screening.

Ensure APCM is not billed simultaneously with Transitional Care Management during the 30-day post-discharge window.

Use AI call data to track how many ED visits were averted through timely telephonic triage and care coordination.

Log all outreach efforts made to close clinical care gaps identified in the ACO’s population health analytics platform.

Ensure APCM encounters support accurate HCC coding to maintain appropriate benchmark levels for the ACO.

Use AI to automatically transcribe and time-stamp all patient interactions for audit-proof APCM documentation.

Deploy AI voice agents to route high-risk patients to clinical staff while handling routine scheduling and queries.

Verify that all AI-generated summaries and call logs are encrypted and integrated directly into the ACO's EHR.

Use AI to ensure consistent messaging across the entire ACO network for APCM outreach and education.

Track and report on wait times for APCM patients to meet CMS standards for timely access to clinical staff.

Sample 5% of APCM claims monthly to ensure time logs match billed units and clinical notes are present.

Use a centralized platform that aggregates APCM participation and compliance metrics across all participating practices.

Document that all care coordinators have been trained on APCM rules and ACO-specific quality objectives.

Create a standard export format containing consent, care plan history, time logs, and encounter notes for auditors.

Ensure AI and call center partners maintain SOC2 Type II compliance for protecting beneficiary health information.