The Centers for Medicare & Medicaid Services (CMS) is amending the PY 2024 participation agreement to manage concerns around Significant Anomalous High Spending (SAHS) billing, an issue observed in 2023 that impacts payment accuracy within the ACO REACH model, especially as healthcare providers look ahead to the 2025 Model year. For the 2023 Final Financial Settlement, CMS will adjust expenditure calculations to account for SAHS billing activities.
Understanding SAHS Billing Activity
SAHS billing refers to instances where specific Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes show a substantial surge in billing, either in volume or dollar amount. This increase is significant when it deviates from established historical trends, has a national or regional impact, and cannot be attributed to policy changes or shifts in supply and demand. Such billing activity, if unaddressed, could lead to inaccurate and unfair payments within the ACO REACH model, affecting the financial stability and predictability for participating organizations as they plan for the 2025 model and beyond.
PY 2023 Adjustments and Impact of HCPCS Codes A4352 and A4353
In Performance Year 2023, CMS identified HCPCS codes A4352 and A4353, related to intermittent urinary catheter supplies, as meeting SAHS criteria. Consequently, this SAHS billing will be excluded from PY 2023 expenditure calculations. The retrospective trend adjustment and stop-loss mechanisms will be recalculated, omitting these SAHS billings to ensure financial integrity for the current performance year and to set a more accurate baseline for future years, including informing strategies for the 2025 model. However, it’s important to note that these codes will still be factored into the Historical Base Year Expenditures calculation used to establish the financial benchmark for PY 2023, based on claims from 2017-2019.
Implications for PY 2024-2026 and Future Guidance
Looking forward, for PY 2024 through PY 2026, CMS will continue to exclude these identified codes from contributing to the historical baseline expenditure calculations when 2023 is used as a base year. This consistent approach aims to provide stability and predictability in financial benchmarks for ACO REACH participants as they navigate the complexities of value-based care in the coming years, including strategic planning for the 2025 model year. CMS has indicated that further guidance will be released concerning how SAHS billing activity will be generally addressed for PY 2024 and PY 2025, ensuring ongoing adaptation and refinement of the ACO REACH model to maintain payment accuracy and program integrity.
