On Monday, April 29, the National Association of Accountable Care Organizations (NAACOS), together with ten other healthcare provider organizations, sent a letter to the administrator of the Center for Medicare & Medicaid Services (CMS), Chiquita Brooks-Lasure, requesting that ACOs be held harmless from irregular Medicare spending beyond their control.
“In 2023, ACOs noticed significantly higher spending for two catheter codes,” the letter stated. “The Institute for Accountable Care analyzed Medicare claims for these two codes from the CMS Virtual Research Data Center and discovered a nearly 20-fold increase in just two years, with spending increasing from $153 million in 2021 to $3.1 billion in 2023. Furthermore, almost all the increase was attributed to just ten suppliers.”
Lacking a remedy, the coalition of healthcare providers stated, ACOs will be unfairly penalized, jeopardizing their continued involvement. The organizations request that CMS take the following actions:
- The removal of catheter expenses from ACO financial calculations in 2023. The letter writers reasoned that ACO benchmarks are meant to be a fair estimate of anticipated spending.
- Create an outlier policy to account for similar variations in unusual spending. This entails examining outlying spending patterns and removing those services.
- Providing ACOs with an option for a second reconciliation. In the past, the coalition argued, reports of suspected fraud could take years to be confirmed.
In the request to hold ACOs harmless from irregular spending, the letter noted, “Akin to the COVID-19 Public Health Emergency, this spending is far outside of the control of any clinician, hospital, other provider, or organization engaged in population health management.”
Earlier in April, Healthcare Innovation reported that during the spring meeting of NAACOS, CMS’ leadership was asked to respond to growing concerns about the impact of widespread anomalous billing and suspected fraud on Medicare ACO results.
There are opportunities to improve how fraud is reported, the letter writers observed, and to further educate ACOs on the fraud investigation process. The coalition requested CMS continue to work on long-term solutions to address suspected and confirmed fraud.
In addition to NAACOS, the letter was signed by Accountable for Health, America’s Physician Groups, the American Hospital Association, the American Medical Association, AMGA, the Association of American Medical Colleges, the Federation of American Hospitals, the Health Care Transformation Task Force, Medical Group Management, and Premier, Inc.
