CHA News

CMS Proposal Seeks to Mitigate Abnormal DME Billing in Medicare Shared Services Program

What’s happening: The Centers for Medicare & Medicaid Services (CMS) released a proposed rule on abnormal billing activity within the Medicare Shared Savings Program.  

What else to know: The proposed rule seeks to mitigate the impact of the billing activity on reconciliation of accountable care organization (ACO) payments in calendar year (CY) 2023. 

The proposed rule would address “significant, anomalous, and highly suspect” (SAHS) billing activity within the Medicare Shared Savings Program, including durable medical equipment, prosthetics, orthotics, and supplies billing. 

In an ongoing investigation, CMS has observed billing volume in CY 2023 for two types of intermittent urinary catheter codes representing SAHS billing activity. CMS proposes to exclude payment amounts for two codes submitted by any supplier from expenditure and revenue calculations for CY 2023, including when CY 2023 is the performance year, or when it is used for establishing benchmarks for 2024, 2025, and 2026. CY 2023 amounts would also be excluded from factors used in the application cycle for ACOs applying to enter a new agreement period beginning on Jan. 1, 2025. 

Comments are due to CMS by July 29.