CMS Action to Rectify Significant Medicare Billing Anomalies: What You Need to Know

Centers for Medicare & Medicaid Services

WASHINGTON, D.C. — The Centers for Medicare & Medicaid Services (CMS) has laid out a strategic proposal to tackle issues of significant, anomalous, and highly suspect (SAHS) billing activities within Accountable Care Organizations (ACOs). The proposal, 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-P), emphasizes on maintaining the fairness and integrity of Shared Savings Program financial calculations.

The alleged SAHS billing activities could potentially undermine Medicare’s essential financial calculations, particularly in the light of increased billings for specific medical supplies related to urinary catheters. This noticeable uptick in billing volume, if unaddressed, could wreak havoc on the balance and accuracy of the program’s calculations.

The CMS’s proposal strives to address these financial discrepancies by modifying the methodology used in the Shared Savings Program. If adopted, these changes will exclude payment amounts for certain medical supplies from expenditure and revenue calculations.

The fallout from these billing abnormalities could spread beyond ACOs. Medical suppliers, healthcare providers, and even Medicare beneficiaries could feel the impact. The CMS is therefore seeking input from the public on these proposed changes. The 30-day comment period runs until July 29, 2024.

While promising to rectify billing discrepancies, the proposed changes may cause short-term disruptions in the Medicare Shared Savings Program. Initial determinations and earned performance payment disbursements for 2023 could be potentially delayed by up to six weeks.

The CMS seems willing to shoulder these short-term disruptions in the view of nurturing long-term financial integrity. By doing this, they aim to ensure that the Shared Savings Program robustly serves ACOs, providers, suppliers, and Medicare beneficiaries with accuracy and fairness.

The modifications, if adopted, would significantly impact the eligibility criteria for the advance investment payment option and the ACO Primary Care Flex Model for the agreement period beginning January 1, 2025. This move is a clear sign that CMS is prepared to make tough decisions to safeguard the financial health of the Medicare program.

In the end, these proposed changes underline CMS’s commitment to creating a financially sustainable and fair Medicare environment. The implications are huge: if successful, this might just set a new precedent in ensuring the integrity of healthcare billing processes, not just for Medicare, but potentially for the wider healthcare industry.

For the latest news on everything happening in Chester County and the surrounding area, be sure to follow MyChesCo on Google News and Microsoft Start.