On Jul 3, CMS published proposal re data inputs, account for fraud.
CMS issued a proposed rule to account for potential fraudulent Medicare claims for catheters and downstream impact to accountable care organizations' (ACO) subsidies.
Title, Mitigate impact of significant, anomalous, and highly suspect billing activity on Medicare Shared Savings Program financial calculations in calendar year 2023.
Program Background
CMS assesses performance year (PY) financial information from ACOs of physicians, hospitals, suppliers to allocate Medicare Shared Savings Program (MSSP) pay backs.
Compensate Medicare ACOs based on quality of care, cost efficiencies, coordination.
Must reduce Medicare Parts A, B expenditures while increasing quality of care scores.
At issue, MSSP regulations do not provide a basis for CMS to adjust program expense or revenue calculations based on the impact of a suspect billing activity, (42 CFR 425).
Recently, ACOs raised concern about increased Medicare billing for intermittent urinary catheter supplies, so-called significant, anomalous and highly suspect (SAHS) billing.
On CMS Durable medical equipment, prosthetics, orthotics. supplies (DMEPOS) claims.
This SAHS issue may not only increase an affected ACO's reduction in pay back and portion of shared losses but also falsely inflate a non-affected ACO's US-regional score.
Distort historical benchmarks for agreements for 2024 - 2026 that rely on 2023 data.
Key Proposed Actions
Exclude all Medicare A or B payments for selected codes from expense and revenue.
Remove payments for specified catheter codes and then adjust PY 2023 expenditures.
Payment amounts would be removed for all suppliers not just those claiming SAHS.
Key Potential Issue
Proposed actions, modifications will delay CMS to send historical benchmark reports to ACOs; this could create issues to forecast Medicare, MSSP expenses and reduce costs..
Consultation
Comments should reference CMS-1799-P and must be received by Mon., Jul. 29, 2024.
Sep. 2024 CMS Final Rule
On Sep. 27, 2024, CMS issued the final rule on mitigating suspect billing activities.
Also, issued Shared Savings Program fact sheet summarizing main parts of rule.
Policies for assessing performance year 2023 Medicare Shared Savings Program ACOs.
Establishes benchmarks for ACOs starting agreement periods in 2024, 2025, 2026.
Calculating factors used in application cycle for ACOs applying for new agreement period beginning Jan. 1, 2025, and change request cycle for continuing participation.
Also, as a result of SAHS billing activity for selected intermittent urinary catheters on Medicare Durable Medical Equipment, Prosthetics, Orthotics & Supplies claims.
Under Shared Savings Program, providers and suppliers that participate in ACOs continue to receive traditional Medicare fee-for-service payments under Parts A and B.
But the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements; participating in 2-sided models may share in losses.
