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Proposed Rule Targets 'Highly Suspect' Billing in Shared Savings Program

Analysis  |  By Jasmyne Ray  
   July 02, 2024

The rule is part of larger plan to address anomalous spending in the program.

After noting a significant increase in highly suspect claims for Healthcare Common Procedure Codes (HCPCS), The Centers for Medicare & Medicaid Services (CMS) is proposing a new rule to crack down suspicious billing activity.

CMS officials have reported a significant increase in SAHS (significant, anomalous and highly suspect) claims for codes for urinary catheters, tips, and insertion supplies during 2023, and the corresponding HCPCS codes were flagged for SAHS billing.

The proposed rule will exclude payouts for codes A4352 and A4353 on DMEPOS claims from the expenditure and revenue calculations used to assess financial performance for accountable care organizations (ACO) for 2023. These calculations will also establish benchmarks for organizations starting agreements in 2024, 2025, and 2026.

The decision comes as part of a larger strategy to address SAHS claims within the Medicare Shared Savings Program, which will be explained further in the CY 2025 Physician Fee Schedule.

In a statement, Jennifer Holloman, the American Hospital Association’s senior associate director of policy,  said the rule is a “significant” step to address anomalous spending, and it won’t be the last.

“We hope the upcoming CY 2025 Physician Fee Schedule will provide additional details to support longer term strategies to address anomalous spending,” she said.

According to CMS, the proposed rule could delay the disbursement of initial ACO payments for 2023 by up to six weeks.

Jasmyne Ray is the revenue cycle editor at HealthLeaders. 


An increase in SAHS claims for urinary catheters instigated the proposal.

Payouts for codes related to SAHS claims will exclude calculations assessing ACO financial performance.

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