CMS has issued a final rule that is part of a broader effort to address suspicious billing activity in Accountable Care Organizations' financial reconciliation.
Eight things to know:
1. A proposal in the 2025 physician fee schedule rule aims to address this issue for 2024 and beyond.
2. Two intermittent urinary catheter codes are flagged as highly suspect, and payments for them are excluded. Codes are considered suspect when there is an unexplained spike in claims, either in volume or dollar amounts, at the regional or national level.
3. The two codes identified as suspect are:
- A4352 (Intermittent urinary catheter; Coude tip)
- A4353 (Intermittent urinary catheter with insertion supplies)
4. CMS uses claims data from Medicare Parts A and B to calculate various factors in MSSP, including expenditures for ACO-assigned beneficiaries, the national assignable fee-for-service population and ACO regional service areas.
5. In early 2023, CMS noticed a spike in urinary catheter billings linked to a small group of durable medical equipment suppliers. CMS found that beneficiaries did not receive catheters, physicians did not order them, and the supplies were not needed.
6. The rule finalizes policies for assessing 2023 ACO financial performance, setting benchmarks for ACOs starting in 2024-2026, and calculating factors for ACOs applying for new agreements in 2025, all in response to the suspicious billing for the two urinary catheter codes.
7. The final rule has been applauded by various stakeholders, including Clif Gaus, president and CEO of the National Association of ACOs. "This ensures that clinicians, hospitals, other healthcare providers and ACOs are not unfairly held responsible for this spending," Mr. 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. We look forward to working with CMS to establish permanent policies that address future instances of fraud, waste and abuse at the local level."
8. By implementing this rule, "CMS is demonstrating its commitment to protecting the integrity and sustainability of the program," Soumi Saha, Premier's senior vice president of government affairs said in a statement. "Premier also strongly supports and urges CMS to finalize its proposal in the CY 2025 Medicare Physician Fee Schedule proposed rule that compliments this final rule by addressing SAHS activity in the future. These crucial steps ensure that MSSP ACOs are not unfairly penalized for billing irregularities beyond their control and will help minimize delay in shared distributions."