The Centers for Medicare & Medicaid Services (CMS) is amending the PY 2024 participation agreement to address concerns over Significant Anomalous High Spending (SAHS) billing observed in 2023. This update has significant implications for healthcare providers and organizations participating in the ACO REACH model, not just for the current performance year but also for future planning, including considerations for the 2025 Model of healthcare delivery and financial frameworks.
Understanding Significant Anomalous High Spending (SAHS) Billing
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 activity. This increase can be in terms of volume or dollar amount, indicating a deviation from established historical utilization trends. CMS defines SAHS billing as activity that is unexpected, not attributable to policy changes or market demand fluctuations, and has a national or regional impact, potentially affecting multiple Accountable Care Organizations (ACOs). Such billing levels, if unaddressed, could lead to inaccurate and inequitable payments within the ACO REACH model.
Impact on Performance Year 2023
For Performance Year 2023, CMS has identified two specific HCPCS codes—A4352 and A4353, both related to intermittent urinary catheter supplies—as meeting the SAHS criteria. Consequently, these identified SAHS billing activities will be excluded from the PY 2023 expenditure calculations. The retrospective trend adjustment and stop-loss mechanisms will be recalculated, excluding these SAHS billings. It’s important to note that while these codes are excluded from PY 2023 expenditures, they will still be considered in the calculation of Historical Base Year Expenditures, which are used to establish the financial benchmark for PY 2023, based on claims incurred between 2017 and 2019.
Looking Ahead: SAHS Billing and the 2025 Model
For the performance years spanning 2024 to 2026, CMS will continue to exclude these specific codes from contributing to the calculation of historical baseline expenditures when 2023 is used as a base year. This decision underscores a proactive approach to maintaining the integrity of financial benchmarks and ensuring fair payment structures within the ACO REACH model as it evolves, potentially influencing the 2025 model and beyond. CMS has indicated that future guidance will be released to provide broader details on how SAHS billing activity will be generally addressed for PY 2024 and PY 2025. This forward-looking approach is critical for healthcare organizations as they plan their financial strategies and operational models, including adaptations necessary for the evolving healthcare landscape and the anticipated 2025 model of care delivery. Stakeholders are advised to stay informed about upcoming announcements from CMS to effectively navigate these changes and ensure compliance and optimal performance within the ACO REACH framework and in preparation for future healthcare models.
