There's been an unusual zone of activity in CMS policy, in their area of ACO and "Shared Savings" calculations when the patient billing records contain large dollar amounts of abuse and fraud. CMS is better at "holding harmless" themselves and others, than "holding responsible."
Recall that ACO's generally have Part B fee for service members, and the ACO is held "responsible" for all Part B spending (not just when the bene visits the ACO's own health system.) Abuse and fraud in "regular" Part B adds to the costs "attributed" to the ACO's overall patient management. In a special rule September 24, 2024, CMS created a "hold harmless" escape valve for ACO's whose patients racked up mysterious large bills for catheteres (A4352, A4353). The latter code rose by 5000X as the payments continued to pour out. (89FR79156; All references at bottom).
They turned the rule around quickly (draft, July 3, final, September 24, less than 90 days). Public awareness of the problem dates back to at least 2/15/2024 (here).
CMS awareness dates, at least, to the beginning of the year in question, CY2023 (CMS writes in the press release, "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." CMS calls this SAHS billing, "Significant, Anomalous, and Highly Suspect" billing.
Billing vs Payments
CMS cleverly attributes the problem to a small group of companies with erroneous billing. Does anyone see the problem yet? It's not erroneous billing, it's erroneous payments.
It doesn't require "AI" or super software to detect this. The massive increase in ludicrous amounts of catheters, coming in as "bills," should never (after a month or two) continue to result in payments. It's exactly the same as the completely insane, nonsensical, billion dollars of payments for obscure full sequencing gene codes, often a dozen per each patient, arriving at MACs in 2018-2022. Some MAC systems were able to completely thwart such crazy payments (NGS MAC, the various MolDx MACs) while others paid out patently ludicrous claims patterns and volumes for years on end.
While it's OK to hold harmless the ACO's, who are unaware of fraudulent billing to Part B MACs in real time, the CMS announcements say far too little about firing the idiots in charge of the payments trigggered by the billing.
CMS's weak reply to the payment problem seems to be *(89FR79156), "The proposed changes do not impose new rules or requirements related to provider billing and payment. The proposed changes are specific to ACOs" [and their profit calculations].
###
CMS press release here:
Here's the final rule at 89 FR 79152 (9-27-24, 21pp): "Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year 2023
https://www.govinfo.gov/content/pkg/FR-2024-09-27/pdf/2024-22054.pdf
See Fierce Healthcare:
"Catherer fraud rule finalized...ACO survival concerns"
See Healthcare Dive:
"CMS holds ACOs harmless for highly suspect Medicare billing"
###
