At this week’s National Association of ACOs (NAACOS) spring meeting, Centers for Medicare & Medicaid Services officials were asked to respond to growing concerns about the impact of widespread abnormal billing and suspected Urinary catheter fraud that is affecting Medicare ACOs’ bottom lines. .
According to a February 2024 article in the New York Times, More than 450,000 Medicare beneficiary accounts were billed for urinary catheters in 2023, up from about 50,000 in previous years. The data comes from a report prepared by the Institute for Accountable Care and NAACOS. “The massive increase in catheter billing included $2 billion charged by seven high-volume providers, according to that analysis, potentially accounting for nearly a fifth of all Medicare spending on medical supplies in 2023,” the article noted. of the Times.
Clif Gaus, Sc.D., who announced he would retire as NAACOS executive director this fall, raised the issue during an April 11 panel session with CMS leaders.
Gaus called the durable medical equipment (DME) catheter billing issue “the elephant in the room for everyone here” and asked if and when CMS was going to find a solution to mitigate potential losses for NAACOS members.
“I know the issue of DME fraud is at the forefront of all your minds,” responded Meena Seshamani, M.D., Ph.D., deputy administrator and director of the Center for Medicare. Taking a step back, she added that ACOs are an incredible source of information and an opportunity to understand where there might be abnormal billing. “We want to be able to partner and leverage that,” Seshamani said. “We remind everyone that they can contact the Center for Program Integrity (CPI) when there are concerns with the abnormal billing that you are all seeing, because where there may be abnormal billing that absolutely can affect the bottom line of the shared savings.
He also noted that all ACOs must have compliance plans and in that compliance plan there are requirements to report potential fraud to the OIG. “So I think there are ways that we are partnering now and absolutely exploring and investigating the latest DME fraud with that mindset of how can we make sure that together we are enabling good administration of the Medicare program.”
“We’re really grateful that ACOs are bringing these issues to us,” said Elizabeth Fowler, JD, Ph.D., director of the Center for Medicare and Medicaid Innovation (CMMI) and deputy administrator of the Centers for Medicare and Medicaid Services. . . “I think it is a testament to success, that we all have more and better data. We are using it effectively. “We are eliminating these problems.”
Fowler noted that for ACO REACH, he anticipates being able to share an approach to abnormal billing related to catheters in the coming weeks. “We are actively working on this in terms of a long-term strategy. We want to make sure we are aligned. We don’t want to have a separate solution that works here, but doesn’t align with what Meena is thinking. For the long-term strategy, we will work closely with Meena and how the SSP program is handling those issues, but for REACH organizations, we anticipate being able to share how we will address those issues soon.”
A response from one audience member, a Palm Beach ACO executive, noted that DME misbilling is much larger than CMS executives described it.
“Our ACO went from $62 million in shared savings (the largest amount in the program) to $45 million due to $50 million of erroneous fraud,” he said. “As of 2020 we made 39 submissions to the CPI and the OIG. We submitted 800 signed patient certificates, but our providers paid for the fraud. It wasn’t the trust fund. It wasn’t the taxpayers. It was our suppliers who worked hard on their programs. As a result, we got very embarrassing results. Everyone questioned our organization. Why are they failing? Why did they reduce? We laid off 15 percent of our staff, but it’s much worse than what you described. And it is much worse than just the catheters and the year 2024. So we kindly ask you to address the problem with greater urgency because it really hurts all of us in the room who are directly paying for this evil.”
Fowler noted that because this is an ongoing investigation, they need to be careful in how they talk about this topic. “We cannot call this fraud. We don’t know that this is fraud, so as you may have noticed, we call it abnormal billing. We need to be careful and intentional about how we talk about it. But we are incredibly grateful that your organizations have brought much of this to our attention.”
In a statement, Gaus reflected on his tenure leading NAACOS. “The more than 11 years as CEO have been an immensely enjoyable chapter in my 55-year career. When we founded NAACOS, every founding board member believed we were the future of healthcare in America, and we still believe that,” he said. “I am confident that the board of directors and new CEO will continue to lead the transformation of our healthcare system to a place where all patients can be assured that they receive the highest quality care and value.”
“Clif has been a critical leader in the ACO movement, since the passage of the Affordable Care Act. To this day, he is a strong supporter of healthcare transformation driven by providers who take responsibility for the total cost of care and outcomes to achieve better, more accessible, affordable and equitable care for patients, families and communities. We wish him all the best as he turns the page on this chapter of his career,” said Emily DuHamel Brower, MBA, NAACOS board chair and senior vice president of clinical integration and medical services at Trinity Health, in a statement.
The NAACOS Board of Directors has appointed a search committee that has engaged Korn Ferry in a national search to find the next NAACOS President and CEO.
