CMS final rule holds ACOs harmless for suspect catheter billings
Medicare claims for catheters have increased and CMS found a rise in billings by a small group of durable medical equipment supply companies.
Photo: Andrii Pohranychnyi/Getty Images
The Centers for Medicare and Medicaid Services has issued a final rule on Significant, Anomalous and Highly Suspect (SAHS) billing activity in the Medicare Shared Savings Program.
The final rule concerns financial calculations for 2023 urinary catheter billings and is part of a larger strategy to address billing activity within Accountable Care Organizations (ACOs) reconciliation, CMS said.
In early 2023, CMS identified a concerning rise in urinary catheter billings, which was attributed to a small group of durable medical equipment supply companies. CMS determined that the beneficiaries did not receive catheters and were not billed directly, that physicians did not order these supplies and that the supplies were not needed.
The rule finalizes changes in policy for assessing performance year 2023 financial performance of Medicare Shared Savings Program ACOs.
CMS is excluding payments for the two catheter Healthcare Common Procedure Coding System (HCPCS) codes from the 2023 performance year, a recommendation made by Premier, according to Soumi Saha, senior vice president of Government Affairs for Premier.
It establishes benchmarks for ACOs starting agreement periods in 2024, 2025, and 2026.
A proposal in the 2025 Physician Fee Schedule proposed rule addresses SAHS billing activity for 2024 onward. It also calculates factors used in the application cycle for ACOs applying to enter a new agreement period beginning on January 1, 2025.
WHY THIS MATTERS
The policy holds ACOs harmless for significant, anomalous and highly suspect catheter billings in 2023, according to the National Association of ACOs.
"This ensures that clinicians, hospitals, other healthcare providers, and ACOs are not unfairly held responsible for this spending," said NAACOS President and CEO Clif Gaus.
ACOs already identify and report anomalous and highly suspect billing, Gaus said.
"While this rule holds ACOs harmless for a broad national instance of suspected fraud, anomalous billing is typically identified at the local level," he said.
There has been a 20-fold increase in Medicare claims related to catheters over the past two years, according to Premier.
THE LARGER TREND
Generally, an HCPCS or Current Procedural Terminology (CPT) code exhibits such suspicious billing activity when there is a significant increase in claims, either in volume or dollars. These claims represent a deviation from historical utilization trends and are not clearly attributable to reasonably explained changes in policy or the supply or demand for covered items or services, CMS said.
CMS uses payment amounts on Medicare Parts A and B claims to calculate various factors used in MSSP financial calculations. This includes expenditures for people assigned to an ACO, expenditures for the national assignable fee-for-service population and the assignable population in an ACO's regional service area, as well as in calculations used to determine ACO revenue status.
Email the writer: SMorse@himss.org
