CMS rule targets suspect billing in Shared Savings Program

CMS has issued a final rule as part of a larger strategy to address "significant, anomalous and highly suspect" billing activity within the Medicare Shared Savings Program in calendar year 2023.

The calendar year (CY) 2025 Physician Fee Schedule (PFS) proposed rule calls for the creation of a methodology to address "significant, anomalous and highly suspect" (SAHS) billing activity for CY 2024 onwards.

CMS uses payment amounts on Medicare Parts A and B claims to calculate various factors used in Shared Savings Program financial calculations, including the following:

• Expenditures for people assigned to an accountable care organization (ACO).
• Expenditures for the national assignable fee-for-service (FFS) population.
• The assignable population in an ACO's regional service area.
• ACO revenue status (high revenue or low revenue).

In early 2023, CMS noticed a rise in urinary catheter billings 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, and physicians did not order these supplies.

The observed billing for A4352 (Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric or hydrophilic, etc.), and A4353 (Intermittent urinary catheter, with insertion supplies) represents SAHS billing activity.

Generally, a Healthcare Common Procedure Coding System (HCPCS) or CPT code indicates SAHS billing activity when there is a significant increase in claims with national or regional impact that deviates from historical utilization trends and is not clearly attributable to reasonably explained changes in policy or supply or demand for covered items or services.

The 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.
• 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.

Clif Gaus, Sc.D., president and CEO of the National Association of ACOs (NAACOS), applauded CMS for finalizing policies to hold ACOs accountable for SAHS billing activity in 2023.

"This ensures that clinicians, hospitals, other healthcare providers and ACOs are not unfairly held responsible for this spending," Gaus said in a press release.

"ACOs serve as a steward of the Medicare program by regularly analyzing data and identifying opportunities to improve care for beneficiaries," Gaus continued. "As part of this work, ACOs readily identify and report anomalous and highly suspect billing. While this rule holds ACOs harmless for a broad national instance of suspected fraud, anomalous billing is typically identified at the local level."

Gaus indicated that NAACOS looks forward to collaborating with CMS to "establish permanent policies that address future instances of fraud, waste and abuse at the local level."

The final rule is 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" (CMS-1799-F).

Hannah Nelson has been covering news related to health information technology and health data interoperability since 2020.