There was a brouhaha this spring that some areas had massive, likely illegitimate charges and spending for "catheters," and this was messing with ACO accounting rules and shared savings results.
In response, CMS has released a new proposed rule that would exclude defined "anomalous spending" from such calculations. Find it here:
American Hospital Association writes about it:
The new acronym is SAHS, significant, anomalous, and highly suspect billing.
- See also HealthLeaders and RevCycle and Fierce Healthcare.
- I've said for years that most Medicare fraud doesn't require super algorithms or (now) AI, but can be picked up by a 12 year old using Excel.
The proposal has a truncated comment period to July 29.
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AI Corner
Here's a Chat GPT summary of the 13-page rule.
The rule you uploaded focuses on addressing significant anomalous billing activities that could impact Medicare Shared Savings Program financial calculations. Specifically, it proposes revisions for the 2023 financial performance assessments of Medicare Shared Savings Program Accountable Care Organizations (ACOs), setting benchmarks for new agreement periods starting from 2024 onwards, and adjusting the factors used in the application and change request cycles for ACOs.
Here are the key points:
Anomalous Billing Activity Detection: The proposal highlights an increase in billing for selected intermittent urinary catheter supplies under Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims in 2023, which is suspected to be fraudulent. This has led to concerns about inflated Medicare Parts A and B payment amounts, potentially skewing ACO financial performance and benchmark calculations.
Proposed Adjustments: CMS proposes to exclude the affected DMEPOS claims from the financial calculations of ACOs to prevent inaccurate payment adjustments and shared savings or losses determinations. This exclusion is intended to ensure that ACO performance evaluations and financial reconciliations are based on legitimate and representative service use.
Operational Changes: The rule suggests adjustments to several operational aspects of the Shared Savings Program, including how performance year expenditures are calculated and benchmarks are set. These changes aim to mitigate the impacts of anomalous billing activities on ACO financial outcomes.
Public and Stakeholder Impact: The proposal also considers the potential impacts on various stakeholders, particularly how it could affect the financial operations of ACOs. It discusses the need for timely adjustments to maintain the integrity and trustworthiness of the Shared Savings Program.
This proposed rule underscores the importance of accurate financial reporting and the need for mechanisms to adjust calculations when unexpected or fraudulent activities distort the expected expenditures of ACOs.
"It sounds like an embarassing situation at CMS..."
The issue of fraud, particularly in complex systems like Medicare, is a challenging one for CMS, and they are certainly aware of the implications and risks associated with fraudulent activities. Here’s how CMS generally handles these situations:
Detection and Investigation: CMS uses various data analytics and monitoring systems to detect unusual billing patterns that deviate from normal activities. When a significant, anomalous, and highly suspect (SAHS) billing activity is identified, as described in the document you uploaded, CMS investigates these patterns further to determine if they are indeed fraudulent.
Actions Taken: If fraud is suspected or confirmed, CMS takes several actions:
- Referral to Law Enforcement: Suspect activities are referred to appropriate law enforcement agencies for further investigation and potential prosecution.
- Recovery of Funds: CMS attempts to recoup any payments that were made fraudulently.
- Exclusion of Providers: Entities found to be involved in fraudulent activities can be excluded from participating in Medicare and other federal health programs.
Policy Adjustments: To prevent future occurrences, CMS often revises policies and introduces new measures. This can include adjusting how payments are calculated and benchmarks are set for ACOs to ensure that anomalous billing activities do not unfairly influence financial outcomes.
Public Transparency and Rulemaking: Through the notice and comment rulemaking process, CMS provides transparency about issues and gathers feedback from various stakeholders. This process helps refine the strategies for handling and preventing fraud, demonstrating an effort to be transparent rather than to "whitewash" any issues.
While the discovery of fraud can be seen as an embarrassment, it is also a part of the ongoing challenge of managing a vast and complex healthcare system. CMS's proactive adjustments and transparency in handling these issues are part of their commitment to maintaining the integrity of the Medicare program.
