Monday, July 15, 2024

Medicare Takes Action: CMS Proposes Rule to Address Anomalous Billing in Shared Savings Program

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Medicare is at the forefront as the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule titled, “Medicare Program: Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year 2023”. This proposed rule is part of a broader strategy to address significant, anomalous, and highly suspect (SAHS) billing activities within Accountable Care Organization (ACO) reconciliation. Additional information will be provided in the forthcoming Physician Fee Schedule.

The proposed rule includes several modifications to the Medicare Shared Savings Program (Shared Savings Program). The CMS has opened a 30-day public comment period on the SAHS billing activity proposed rule, inviting comments from all interested parties, including ACOs, providers, suppliers, and Medicare beneficiaries. The comment period will close on July 29, 2024.

CMS uses payment amounts on Medicare Parts A and B claims to calculate various factors used in Shared Savings Program financial calculations. These factors include expenditures for beneficiaries assigned to an ACO, expenditures for the national assignable fee-for-service (FFS) population, the assignable population in an ACO’s regional service area, and calculations used to determine ACO revenue status (high revenue or low revenue). Recently, CMS has observed an increase in Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) billing to Medicare for selected intermittent urinary catheter supplies in CY 2023. If unaddressed, this increase could adversely impact the accuracy, fairness, and integrity of Shared Savings Program financial calculations.

CMS Proposes Exclusion of Specific HCPCS Codes to Address Anomalous Billing in Medicare

The observed DMEPOS billing volume for Healthcare Common Procedure Coding System (HCPCS) codes A4352 (Intermittent urinary catheter; Coude (curved) tip, with or without coating) and A4353 (Intermittent urinary catheter, with insertion supplies) represents SAHS billing activity. A HCPCS or Current Procedural Terminology (CPT) code exhibits SAHS billing activity when there is a significant increase in claims, either in volume or dollars, with national or regional impact.

This increase represents a deviation from historical utilization trends that is unexpected and not clearly attributable to policy changes or the supply or demand for covered items or services. In this proposed rule, CMS proposes to exclude payment amounts for the two HCPCS codes on DMEPOS claims submitted by any supplier from expenditure and revenue calculations.

The proposed rule aims to assess the performance year (PY) 2023 financial performance of Shared Savings Program ACOs, establish benchmarks for ACOs starting agreement periods in 2024, 2025, and 2026, and calculate factors used to determine revenue status and repayment mechanism amounts in the application and change request cycles for ACOs applying to enter a new agreement period beginning on January 1, 2025, or continuing their participation in the program in PY 2025.

The modifications to the Shared Savings Program financial methodology in this proposed rule are anticipated to delay by up to six weeks the issuance of initial determinations and disbursements of earned performance payments for PY 2023. This delay would allow CMS to maintain timely adjudication of certain determinations of applicant ACOs’ eligibility to participate under the advance investment payment option or the ACO Primary Care Flex Model for an agreement period beginning January 1, 2025.


CMS Seeks Feedback on Rule to Address Billing Anomalies in Medicare Shared Savings Program

It would also ensure timely finalization of repayment mechanism arrangements required for ACOs to enter or continue their participation in two-sided models for PY 2025. Furthermore, the proposed modifications would delay the calculation of final historical benchmarks and the delivery of related reports for ACOs that entered an agreement period beginning on January 1, 2024.

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CMS encourages all interested parties to participate in the public comment period to ensure that the final rule reflects a comprehensive understanding of the concerns and suggestions of various stakeholders. By engaging in this process, ACOs, providers, suppliers, and Medicare beneficiaries can contribute to the development of policies that enhance the integrity and effectiveness of the Medicare Shared Savings Program.

The proposed rule by CMS aims to address the significant, anomalous, and highly suspect billing activities observed in the Medicare Shared Savings Program. By excluding specific HCPCS codes from financial calculations and making necessary adjustments, CMS seeks to maintain the accuracy, fairness, and integrity of the program. The 30-day public comment period provides an opportunity for stakeholders to voice their opinions and contribute to the finalization of the rule, ensuring that it effectively mitigates the impact of SAHS billing activities on the program’s financial calculations.


Resource: Centers for Medicare and Medicaid Services, June 28, 2024

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