Main Library
First catheters, now skin substitutes—and more areas of anomalous medical billing will continue to pop up, requiring data vigilance and collaboration on the part of accountable care organizations (ACOs), according to speakers at the National Association of ACOs (NAACOS) Spring 2025 Conference. The identification of these areas potentially signaling fraud aligns with the Trump administration’s focus on promoting efficiency and cutting out waste, as described by new CMS Administrator Mehmet Oz, MD.
A Catheter Conundrum Threatened ACO Savings in 2024
Anomalous billing for durable medical equipment (DME) such as catheters was a hot topic at last spring’s NAACOS meeting,1 and according to the chair of today’s session, “Unmasking Fraud in Value-Based Care: Lessons from 2023 DME Settlements and Strategies for the Next Wave,” the issue has only grown in importance. Gabe Orthous, MBA, director of value-based services and analytics, Health Choice Care, described how fraud can take multiple forms: DME that is billed but not delivered, DME that is unnecessarily provided, kickbacks for DME suppliers, or billing for custom-fitted DME that is actually standard issue.
The pattern of anomalous billing for catheters, which CMS addressed last year by excluding certain billing codes from shared savings calculations,2 “changed the dynamic of how we get paid,” Orthous said. “It changed the dynamic of our funds flow. It changed our dynamic of how we look at utilization in general, how our quarterly expenditure reports looked.”