CMS to 'hold ACOs harmless' for catheter fraud scandal

Accountable care organizations concerned they would be held responsible for bad actors exploiting the Medicare system can breathe a sigh of relief.

The Centers for Medicare & Medicaid Services (CMS) stepped in Friday and proposed a rule that ensures they are safe from unfair financial ramifications.

The rule (PDF), if finalized, would exclude payment amounts for certain intermittent urinary catheters submitted from suppliers used for assessing performance year 2023 financial performance of Medicare Shared Savings Program (MSSP) ACOs. Benchmarks will be set for 2024, 2025 and 2026, the agency said in a news release.

“[The National Association of ACOs (NAACOS)] applauds CMS for implementing stakeholder recommendations to hold ACOs harmless for significant anomalous and highly suspect catheter expenditures in 2023,” said Clif Gaus, the group's president and CEO, in a statement. “This ensures that clinicians, hospitals, other healthcare providers and ACOs can remain in the models and are not unfairly penalized. We look forward to working with CMS to establish permanent policies that will address future instances of fraud, waste and abuse, as well as streamline the process for identification and reporting.”

NAACOS and ACOs had discovered unusual irregularities suggesting payments to beneficiaries increased dramatically. Without federal action, ACOs could receive less funds from benchmarking calculations, jeopardizing the sustainability of ACOs to no fault of their own.

CMS’ action was also supported by Premier Inc.

“Premier applauds CMS for adopting our recommendation to exclude payments for the two catheter HCPCS codes from the 2023 performance year, protecting MSSP ACOs from unjust repercussions due to [significant, anomalous and highly suspect (SAHS)] billing,” said Soumi Saha, senior vice president of government affairs.

SAHS billing activity is not currently accounted for under the MSSP by CMS. The agency said it is looking to change this policy.

“Specifically, we are concerned that absent mitigation measures, this SAHS billing activity would inflate Medicare Parts A and B payment amounts,” the rule said. “Failing to address SAHS billing activity that occurred in CY 2023 would jeopardize the integrity of the MSSP.”

In April, CMS teased a solution to ACOs' woes, indicating the agency was looking at ways to solve SAHS concerns regarding the ACO REACH program. CMS officials encouraged ACOs to contact the CMS Center for Integrity if they notice other irregularities.