The Centers for Medicare and Medicaid Services (CMS) has released a proposed rule aimed at mitigating the impact of significant, anomalous, and highly suspect billing activity on Medicare Shared Savings Program (MSSP) financial calculations in Calendar Year 2023 (CMS-1799-P). This proposed rule is a crucial step in ensuring the integrity and accuracy of MSSP financial calculations, which are essential for the program’s success. Background

The MSSP is a Medicare program that encourages accountable care organizations (ACOs) to provide high-quality, cost-effective care to Medicare beneficiaries. ACOs are incentivized to reduce costs and improve patient outcomes, and their financial performance is evaluated based on their ability to achieve these goals. Significant, Anomalous, and Highly Suspect Billing Activity

However, some ACOs may engage in significant, anomalous, and highly suspect billing activity, which can distort their financial performance and undermine the integrity of the MSSP. This proposed rule aims to address this issue by identifying and mitigating the impact of such activity on MSSP financial calculations. Proposed Changes

The proposed rule includes several changes aimed at addressing significant, anomalous, and highly suspect billing activity. These changes include:

• Identification of Anomalous Claims: CMS proposes to identify claims that are significantly higher or lower than expected, and to investigate these claims to determine if they are anomalous or highly suspect.
• Adjustment of Claims: If an anomalous claim is identified, CMS proposes to adjust the claim to reflect a more accurate payment amount.
• Exclusion of Highly Suspect Claims: CMS proposes to exclude highly suspect claims from MSSP financial calculations to prevent them from distorting the ACO’s financial performance. Impact on ACOs

The proposed rule is expected to have a significant impact on ACOs participating in the MSSP. ACOs that engage in significant, anomalous, and highly suspect billing activity may face financial penalties or even exclusion from the program. On the other hand, ACOs that provide high-quality, cost-effective care may benefit from the proposed changes by having their financial performance accurately reflected in the MSSP. Conclusion

The proposed rule on mitigating the impact of significant, anomalous, and highly suspect billing activity on MSSP financial calculations is a crucial step in ensuring the integrity and accuracy of the program. The proposed changes are expected to have a significant impact on ACOs participating in the MSSP, and will help to ensure that the program is delivering high-quality, cost-effective care to Medicare beneficiaries. Medvise