APCM Compliance & Audit Checklist for Value-Based Care

Document the comprehensive initiating face-to-face visit for new patients or those not seen in 12 months prior to APCM enrollment.

Maintain verifiable, documented verbal or written consent for APCM services within the EHR, including notification of cost-sharing.

Prove continuous access to care via AI-powered call routing or clinical staff to address urgent needs outside of office hours.

Ensure every patient has a digital care plan addressing physical, mental, and social health goals that is accessible to the entire care team.

Document thorough medication reviews and reconciliation to prevent adverse events and reduce the total cost of care.

Verify all APCM-related activities, including automated outreach and patient responses, are timestamped and logged in a certified EHR.

Map APCM outreach activities directly to HEDIS and MIPS quality measures to ensure performance bonuses and shared savings.

Use AI call handling to proactively schedule screenings for colorectal cancer, mammograms, and annual wellness visits.

Document regular outreach for blood pressure control and HbA1c management for high-risk diabetic populations.

Screen for and document Social Determinants of Health (SDOH) barriers, linking patients to community resources via automated follow-ups.

Track and document proactive interventions and triage calls that successfully prevented avoidable emergency department visits.

Collect and log patient-reported outcome measures to demonstrate clinical improvement for value-based contract reporting.

Ensure clinical documentation supports accurate Hierarchical Condition Category (HCC) coding for appropriate risk adjustment scores.

Regularly audit claims to ensure APCM is not billed concurrently with overlapping codes like CCM, PCM, or TCM.

Verify that APCM workflows satisfy specific quality and documentation requirements found in private payer VBC contracts.

Correlate APCM activity levels with reductions in total cost of care to justify program ROI to ACO leadership.

Utilize AI tools to generate monthly compliance reports for executive leadership and board review to ensure audit readiness.