On September 24, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the final rule entitled, “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-F). This final rule is part of a larger strategy to address significant, anomalous, and highly suspect (SAHS) billing activity within Accountable Care Organizations (ACOs) reconciliation. A proposal in the calendar year (CY) 2025 Physician Fee Schedule (PFS) proposed rule addresses SAHS billing activity for CY 2024 onwards. This fact sheet summarizes the Medicare Shared Savings Program (Shared Savings Program) policies that are included in this final rule.
CMS uses payment amounts on Medicare Parts A and B claims to calculate various factors used in Shared Savings Program financial calculations, including expenditures for people assigned to an ACO, expenditures for the national assignable fee-for-service (FFS) population, and the assignable population in an ACO’s regional service area, as well as in calculations used to determine ACO revenue status (high revenue or low revenue). 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.
The observed billing for A4352 (Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), and A4353 (Intermittent urinary catheter, with insertion supplies) represents SAHS billing activity.
Generally, an HCPCS or Current Procedural Terminology (CPT) code exhibits SAHS billing activity when there is a significant increase in claims, either in volume or dollars, with national or regional impact, which represents a deviation from historical utilization trends that is unexpected and is not clearly attributable to reasonably explained changes in policy or the supply or demand for covered items or services. This rule finalizes changes in policies for assessing performance year (PY) 2023 financial performance of Shared Savings Program ACOs; establishing benchmarks for ACOs starting agreement periods in 2024, 2025, and 2026; and calculating factors used in the application cycle for ACOs applying to enter a new agreement period beginning on January 1, 2025, and continuing their participation in the program for PY 2025, as a result of SAHS billing activity for the two intermittent urinary catheter codes.