MSSP Final Rule to Address Anomalous Catheter Billing in 2023
On September 24, 2024, CMS released a final rule to mitigate the impact of suspected catheter-related Durable Medical Equipment (DME) fraud; referred to by CMS as “Significant, Anomalous, and Highly Suspect Billing Activity” or “SAHS” on Medicare Shared Savings Program (MSSP) ACO financial calculations for calendar year 2023 (CY2023). The finalized policies come in response to reports by ACOs who noticed concerning increases in catheter-related DME spending, and Medicare patients themselves who noticed billing for services they did not receive.
In this blog, we provide answers to key questions ACOs may want to know about this final rule. While the final rule specifically governs MSSP, CMMI has released guidance that ACO REACH will align its policies with MSSP to address SAHS billing activity in program year (PY) 2023.
At a high level, what did CMS finalize in this rule?
CMS finalized excluding 2023 catheter-related DME claims from ACO performance year and benchmark calculations to avoid situations where ACOs see significant impact to their savings or losses as a result of the unanticipated and significant increases in billing for catheters in 2023. The exclusions will apply to the ACO’s expenditures as well as regional and national calculations used to develop and trend the benchmark.
Which specific claims will be excluded from ACO calculations?
CMS will exclude costs for the following codes from ACO financial calculations for dates of service in CY2023:
A4352 Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.)
A4353 (Intermittent urinary catheter, with insertion supplies)
CMS reports a 163% increase in A4352 and a 5000% increase in billing for A4353 from 2022 to 2023.
What calculations will be affected by the exclusions?
CMS will exclude costs from these codes from all CY2023 calculations, including:
ACO performance year expenditures
ACO benchmark year expenditures
Regional and national benchmark amounts and trends
Accountable Care Prospective Trend (ACPT)
Truncation thresholds
Repayment mechanism amounts
High/Low Revenue determinations and its implications for Advance Investment Payment and ACO PC Flex eligibility
Only dates of service in CY2023 will be excluded. This will affect PY2023 financial settlement and benchmark calculations for ACOs in which 2023 is a benchmark year (i.e., ACOs entering a new agreement period in 2024, 2025, and 2026).
The codes referenced above will l not be excluded from other benchmark years (e.g., 2021 and 2022 for ACOs that entered a new agreement period in 2024).
Is the exclusion limited to claims billed by certain DME suppliers or otherwise determined to be “highly suspect”?
No. CMS will exclude all instances of A4352 and A4353 from CY2023 calculations.
Will every ACO’s performance improve as a result of these policies, or could these changes make an ACO’s performance worse?
CMS states that for most ACOs, the inclusion of the specified catheter codes does not substantially change their estimated financial outcome in PY2023. As finalized, some ACOs will perform better, some will perform worse, and many will see no substantial difference. How the exclusion of catheter claims affects a given ACO will depend on how billing and payment for the relevant codes in their attributed population compares to the utilization of those services in the regional and national reference populations and how each has trended over time.
Will PY2023 financial settlement calculations be delayed?
As finalized, CMS anticipates a 6-week delay in issuing financial settlement reports. Annual financial settlement reports are typically issued in early August with payments of shared savings being made in September. As of mid-October, ACOs had not yet received their PY2023 Financial Settlement reports.
Will these policies also apply to ACO REACH? What about other CMMI APMs?
The final rule is specific to MSSP. However, CMMI notified ACOs participating in the ACO REACH Model that they intend to align their policies with the MSSP policies, which is consistent with what CMMI Director, Liz Fowler, has indicated in recent months. Additional guidance for ACO REACH was released on August 1 that states ACO REACH PY 23 expenditures will be adjusted for SAHS billing consistent with the finalized MSSP policy. CMS has not yet indicated if or how any similar policies would be applied to other APMs.
Does this final rule address how CMS will identify and address “SAHS” in the future?
This final rule is specific to dates of service in CY2023. In the CMS Fact Sheet released along with the proposed rule, they indicated that additional details are expected in the Physician Fee Schedule, which was released in early July. In the PFS 2025 proposed rule, CMS makes broader policy proposals about how to handle similar situations in the future. CMS is proposing to routinely examine billing trends to identify and monitor any codes that would trigger the SAHS policy for CY 2024 and beyond. As the 2025 PFS proposed rule was published in late July, we expect the final rule in early November.
Go to the Source(s)
ACO REACH Model Performance Year 2025 Model Update – Quick Reference