At this week’s spring assembly of the Nationwide Affiliation of ACOs (NAACOS), officers from the Facilities for Medicare & Medicaid Providers had been requested to reply to rising considerations concerning the impression of widespread anomalous billing and suspected fraud involving urinary catheters that’s impacting Medicare ACO outcomes.
Based on a February 2024 story within the New York Instances, greater than 450,000 Medicare beneficiaries accounts had been billed for urinary catheters in 2023, up from about 50,000 in earlier years. The information got here from a report produced by the Institute for Accountable Care and NAACOS. “The huge uptick in billing for catheters included $2 billion charged by seven high-volume suppliers, in accordance with that evaluation, doubtlessly accounting for practically one-fifth of all Medicare spending on medical provides in 2023,” the Instances story famous.
Clif Gaus, Sc.D., who introduced he can be retiring as NAACOS CEO this fall, raised the difficulty throughout an April 11 panel session with CMS leaders.
Calling the sturdy medical gear (DME) catheter billing concern “the elephant within the room for everyone right here,” Gaus requested if and when CMS was going to provide you with an answer to mitigate the potential losses to NAACOS members.
“I do know that the the DME fraud concern is entrance and middle in your entire minds,” responded Meena Seshamani, M.D., Ph.D., deputy administrator and director of the Heart for Medicare. Taking a step again, she added that ACOs are an unimaginable supply of knowledge and alternative to know the place there is likely to be anomalous billing happening. “We wish to have the ability to associate and leverage that,” Seshamani stated. “We remind everybody of having the ability to contact the Heart for Program Integrity (CPI) when there are considerations with anomalous billing that you just all are seeing as a result of the place there might be anomalous billing that completely can have an effect on the underside line of shared financial savings.
She additionally famous that each one ACOs should have compliance plans and in that compliance plan there are necessities round reporting to OIG round potential fraud. “So I believe there are methods that we’re partnering now and we’re completely exploring and looking out into the newest DME fraud with that mindset of how can we guarantee that collectively, we’re enabling good stewardship of the Medicare program.”
“We’re actually grateful that that ACOs are bringing these points to us,” stated Elizabeth Fowler, J.D., Ph.D., director of the Heart for Medicare and Medicaid Innovation (CMMI) and deputy administrator of the Facilities for Medicare and Medicaid Providers. “I believe that could be a testomony of success, that all of us have extra and higher knowledge. We’re utilizing it successfully. We’re rooting out these points.”
Fowler famous that for ACO REACH, she anticipates having the ability to share an method for anomalous billing associated to catheters within the coming weeks. “We’re engaged on that actively by way of a long-term technique. We wish to guarantee that we’re aligned. We do not wish to have a separate answer that works over right here, however would not align with what Meena is considering. For the longer-term technique, we’ll be working carefully with Meena and the way the SSP program is dealing with these points, however for REACH organizations, we anticipate having the ability to share how we’ll deal with these points quickly.”
One response from an viewers member, an govt at Palm Seaside ACO, famous that the DME misguided billing is so much larger than how the CMS execs had been describing it.
“Our ACO went from $62 million in shared financial savings — probably the most in this system — all the best way right down to $45 million resulting from $50 million of misguided fraud,” he stated. “Beginning in 2020 we submitted 39 submissions to CPI and the OIG. We submitted 800 signed affected person attestations, however our suppliers paid for the fraud. It wasn’t the belief fund. It wasn’t the taxpayers. It was our suppliers working onerous in your packages. Because of this, we had very embarrassing outcomes. All people questioned our group. Why are you guys failing? Why did you guys scale back? We laid off 15 p.c of our employees, nevertheless it’s a lot worse than what you described. And it is a lot worse than simply the catheters and 2024. So we simply kindly ask that you just deal with the difficulty with the next urgency as a result of it actually hurts all of us within the room which might be instantly paying for this improper.”
Fowler identified that as a result of that is an ongoing investigation, they should watch out by way of how they discuss this concern. “We can’t name this fraud. We do not know that it is fraud, in order you discover, we’re calling it anomalous billing. We should be cautious and intentional about how we discuss it. However we’re extremely grateful that your organizations have introduced a whole lot of this to our consideration.”
In an announcement, Gaus mirrored on his tenure main NAACOS. “The eleven-plus years as CEO have been an immensely pleasurable chapter in my 55-year lengthy profession. Once we based NAACOS, everybody on the founding board believed we had been the way forward for healthcare in America, and we nonetheless do,” he stated. “I’m certain the board and new CEO will proceed to guide the transformation of our well being care system to a spot the place all sufferers might be certain they’re receiving the best high quality care and worth.”
“Clif has been an instrumental chief within the ACO motion, again to the passing of the Inexpensive Care Act. To at the present time, he’s a stalwart supporter of healthcare transformation that’s pushed by suppliers taking accountability for complete price of care and outcomes to attain higher, extra accessible, inexpensive and equitable take care of sufferers, households and communities. We want him all the perfect as he turns the web page on this chapter of his profession,” stated Emily DuHamel Brower, M.B.A., NAACOS board president and senior vp of scientific integration and doctor companies for Trinity Well being, in an announcement.
The NAACOS board of administrators has appointed a search committee that has engaged Korn Ferry in a nationwide search to search out NAACOS’s subsequent president and CEO.
