CMS Issues Rule in Attempt to Mitigate Suspect Billing Activity

The Centers for Medicare & Medicaid Services (CMS) have issued the final rule entitled “Medicare Program: Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year 2023.”

CMS “uses payment amounts on Medicare Parts A and B claims to calculate various factors used in Shared Savings Program financial calculations, including expenditures for people assigned to an ACO, expenditures for the national assignable fee-for-service (FFS) population, and the assignable population in an ACO’s regional service area, as well as in calculations used to determine ACO revenue status (high revenue or low revenue). 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, physicians did not order these supplies, and supplies were not needed.”

This rule “finalizes changes in policies for assessing performance year (PY) 2023 financial performance of Shared Savings Program ACOs; establishing benchmarks for ACOs starting agreement periods in 2024, 2025, and 2026; and calculating factors used in the application cycle for ACOs applying to enter a new agreement period beginning on January 1, 2025, and continuing their participation in the program for PY 2025, as a result of SAHS billing activity for the two intermittent urinary catheter codes.”