/ en Mon, 28 Apr 2025 03:04:07 -0500 Mon, 29 Jul 24 09:42:18 -0500 /2024-07-29-comment-letter-cms-proposed-rule-mitigate-impact-significant-anomalous-and-highly-suspect-billing-activity-within <div class="container"><div class="row"><div class="col-md-8"><p>July 29, 2024</p><p>The Honorable Chiquita Brooks-LaSure<br>Administrator<br>Centers for Medicare & Medicaid Services<br>Hubert H. Humphrey Building<br>200 Independence Avenue, S.W., Room 445-G<br>Washington, DC 20201</p><p><em><strong>RE: Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in CY 2023</strong></em></p><p>Dear Administrator Brooks-LaSure:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers, and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) proposed rule to mitigate the impact of significant, anomalous and highly suspect (SAHS) billing activity within the Medicare Shared Savings Program (MSSP) in calendar year (CY) 2023.</p><p><strong>We applaud CMS for taking quick action to develop proposals to address </strong><a href="/system/files/media/file/2024/04/Coalition-letter-on-Catheter-Spending-Impact-on-ACOs.pdf"><strong>concerns</strong></a><strong> raised by the AHA and other stakeholders regarding the potential impact of SAHS catheter billing.</strong> Specifically, data from the CMS Virtual Research Data Center showed a 20-fold increase in catheter billing on the part of 10 durable medical equipment (DME) suppliers over the course of two years, which was equivalent to an almost $3 billion increase in spending. Inclusion of this anomalous billing in accountable care organization (ACO) spending figures for CY 2023 would have a severely inappropriate impact on these calculations. Indeed, the recent catheter billing issue increased some ACOs’ total spending by as much as 2%. As such, in many cases, inclusion of this spending would actually lead to a loss of shared savings.</p><p><strong>We support CMS’ proposal to hold ACOs harmless for the SAHS catheter billing that occurred in CY 2023. Specifically, we support the exclusion from expenditure and revenue calculations of payment amounts for catheter billing codes submitted by any supplier.</strong> This would include when CY 2023 is the performance year, as well as when it is used for establishing benchmarks for 2024, 2025 and 2026. Additionally, we support that SAHS billing amounts would be excluded from factors used in the application for ACOs applying to enter a new agreement period beginning on Jan. 1, 2025. That said, while this proposed rule would apply only to the MSSP, we encourage the agency also to evaluate impact and pursue similar policies for other ACO programs outside of MSSP. For example, the ACO Realizing Equity, Access, and Community Health (REACH) model appears to have been similarly impacted by anomalous catheter billing.</p><p>We also encourage CMS to evaluate whether additional codes should be carved out of financial calculations for 2023. Some ACOs have reported, for example, that there have been similar increases in billing for skin substitutes (a $2.6 billion increase between 2022 and 2023) that also may artificially skew financial calculations and impact shared savings without action.</p><p>We recognize that even with a 30-day comment period, the process of carving out this spending from financial calculations may result in delays in timelines. Specifically, CMS stated that it anticipates a delay in reconciliation timelines by up to six weeks. <strong>Given the projected delays in reconciliation timelines, we encourage CMS to delay other ACO timelines, such as risk track selection deadlines and participation lists, to ensure alignment.</strong> Indeed, previous performance is an important factor that participants consider when determining whether, for example, they can assume more risk under a different performance track.</p><p>While this proposed rule marks a significant step to mitigate the impact of anomalous catheter spending for CY 2023, this is not the first, and unfortunately likely not the last, instance of ACOs reporting suspected fraudulent billing. <strong>As such, we commend CMS for including proposals to address the impact of SAHS in 2024 and future years as part of the CY 2025 physician fee schedule (PFS) proposed rule.</strong> We have <a href="/system/files/media/file/2024/04/Coalition-letter-on-Catheter-Spending-Impact-on-ACOs.pdf">urged</a> for long-term policies to support the identification of SAHS. For example, we have recommended the establishment of an outlier policy to detect variation in anomalous spending above a certain threshold and remove services from future calculations. There also are opportunities to improve how ACOs report fraud, as well as to better educate ACOs on the process CMS and the Health and Human Services (HHS) Office of Inspector General (OIG) undertake to investigate fraud. As the HHS OIG has previously noted, ACOs are excellent sources to uncover potential fraud, waste and abuse by identifying patterns of unusual billing. We will provide additional comments in response to the CY 2025 PFS proposed rule.</p><p>We appreciate CMS’ timely proposal on this issue and look forward to working collaboratively on developing a longer-term strategy to detect and address anomalous billing. Please contact me if you have questions or feel free to have a member of your team contact Jennifer Holloman, AHA’s senior associate director of policy, at <a href="mailto:jholloman@aha.org?subject=" comment letter proposed rule to mitigate the impact of anomalous and highly suspect billing activity within medicare shared savings program in cy>jholloman@aha.org</a>.</p><p>Sincerely,</p><p>/s/</p><p>Ashley Thompson<br>Senior Vice President<br>Public Policy Analysis and Development</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/07/Comment-Letter-on-CMS-Proposed-Rule-to-Mitigate-the-Impact-of-Significant-Anomalous-and-Highly-Suspect-Billing-Activity.pdf" target="_blank" title="Click here to download the Comment Letter on CMS’ Proposed Rule to Mitigate the Impact of Significant, Anomalous and Highly Suspect Billing Activity within the Medicare Shared Savings Program in CY 2023 PDF."><img src="/sites/default/files/inline-images/Page-1-Comment-Letter-on-CMS-Proposed-Rule-to-Mitigate-the-Impact-of-Significant-Anomalous-and-Highly-Suspect-Billing-Activity.png" data-entity-uuid="e6d08773-8155-4678-a0af-41705f88dd0d" data-entity-type="file" alt="Comment Letter on CMS’ Proposed Rule to Mitigate the Impact of Significant, Anomalous and Highly Suspect Billing Activity within the Medicare Shared Savings Program in CY 2023 page 1." width="692" height="900"></a></p></div></div></div> Mon, 29 Jul 2024 09:42:18 -0500 Fraud <div class="container row"> <div class="row"> <div class="col-md-8"> <p>The FBI Atlanta Field Office, in coordination with the Office of Private Sector, prepared this Liaison Information Report (LIR) to inform medical professionals and healthcare sector members in the Atlanta Area of Responsibility regarding a scheme where criminal actors called licensed medical professionals and suggests their professional licenses have been connected to ongoing criminal investigations. In the telephone calls, the fraudsters impersonate state licensing board representatives, FBI Special Agents, or DEA Special Agents. The criminal actors indicate the medical professional is a subject of a money laundering investigation and request the physician liquidate their accounts and pay thousands of dollars related to the investigations. The money is then disbursed to Coinbase or overseas accounts in Peru or Poland.</p> <ul> <li>In March 2022, a surgeon in Atlanta was contacted by criminal actors, who informed her that she would be arrested, her assets seized, and her medical license suspended as part of an ongoing criminal money laundering investigation. The fraudsters provided what appeared to be official looking Department of Justice, FBI, Department of Treasury, and medical licensing board letterhead documents to prove their claims. The fraudsters instructed the surgeon to wire funds to various secure international accounts controlled by the FBI while the investigation was ongoing. Over the course of one month, the surgeon wired approximately $472,000 to accounts in Peru, Poland and Coinbase Inc. The surgeon received a receipt by fax or text after each transaction, appearing to be from the Drug Enforcement Administration. The impersonators informed the surgeon she may still be subject to asset forfeiture and that in order to prevent this from occurring she would need to increase her debt by taking out a $30,000 bank loan. The surgeon took out a loan as instructed and provided the debit card and account information to the purported agents.</li> <li>In April 2022, fraudsters contacted an Atlanta-based physician purporting to be DEA Special Agents conducting a drug trafficking investigation. An individual identifying himself as a federal agent stated the DEA had intercepted a large quantity of illegally obtained prescription drugs with the physician’s name on the packages. The callers also stated there was a warrant for the physician’s arrest as she was associated with money laundering and drug trafficking. The callers informed the physician she would lose her medical license due to her involvement in the alleged criminal activity. The fraudsters instructed the physician to liquidate her bank account as her social security number was compromised, the agents provided an address to send the funds for safekeeping until she could obtain a new social security number. The victim mailed $12,600 in cash via United States Postal Service (USPS) to a Costa Mesa, California address.</li> <li>In May 2022, an Atlanta-based physician purportedly received a call from the Georgia Composite Medical Board (GCMB) Special Agent. The fraudsters informed her an abandoned vehicle was located in Texas with cocaine and fentanyl prescribed by the physician. The fraudster stated the FBI and DEA contacted the GCMB requesting her medical license be suspended effective immediately as the physician was under investigation. The agents stated she would also be charged with money laundering as numerous accounts were opened with large sums of money totaling $250,000. The fraudsters instructed the physician to travel to a local UPS store to receive a fax, where she received what appeared to be official documents. A purported FBI Special Agent contacted the physician stating her passport was flagged and she would be unable to leave the state or country until the matter was resolved. The fraudsters faxed additional documents on letterhead in reference to federal bond fees and instructed the victim to wire $7,200 to a bank account in Peru. The agents indicated scammers compromised the physician’s accounts and again instructed her to liquidate all her bank and 401K accounts to be transferred to the US government for safe custody until the funds could be returned.</li> </ul> <p>Medical professionals should remain aware of this scam and conduct due diligence if contacted by purported federal agents. The following indicators and mitigation steps should be considered to avoid becoming victims:</p> <ul> <li>Be aware the DEA, FBI, or other federal law enforcement agencies will never solicit payment from a victim or alleged subject during an investigation.</li> <li>Use caution with any requests for payments related to an alleged criminal investigation from any law enforcement official, specifically law enforcement officers who indicate they are based in the United States and request money to be sent to overseas locations for safekeeping.</li> <li>Do not provide personal identifiable information (PII) such as date of birth, social security number, financial information, or professional certification/licensure numbers to suspicious calls, emails, text messages, or social media messages.</li> <li>Conduct verification of personnel claiming to be from state medical boards or law enforcement agencies.</li> </ul> <p>Should you be contacted by a suspected scammer related to this scheme, please report it to your local FBI Field Office and the FBI Internet Crimes Complaint Center (IC3) at <a href="http://www.ic3.gov/" target="_blank">www.ic3.gov</a>.</p> <p>This LIR was disseminated from OPS’s Information Sharing and Analysis Unit. Direct any requests and questions to your FBI Private Sector Coordinator at your <a href="https://www.fbi.gov/contact-us/field-offices" target="_blank">local FBI Field Office</a>: <a href="https://www.fbi.gov/contact-us/field-offices" target="_blank">https://www.fbi.gov/contact-us/field-offices</a></p> </div> <div class="col-md-4"> <div> <p><strong>For help with Cybersecurity and Risk Advisory Services exclusively for AHA members, contact:</strong></p> <h3><a href="/system/files/media/file/2020/11/AHA-Riggi-Senior-Advisor-for-Cyber-and-Risk-Bio-08102020.pdf">John Riggi</a></h3> <h4>Senior Advisor for Cybersecurity and Risk, AHA</h4> <h4><a href="mailto:jriggi@aha.org?subject=Cybersecurity and Risk Advisory Services Query">jriggi@aha.org</a></h4> <h4>(O) <a href="tel:1-202-626-2272">+1 202 626 2272</a></h4> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2020/11/AHA-Riggi-Senior-Advisor-for-Cyber-and-Risk-Bio-08102020.pdf" target="_blank">More on John Riggi</a></div> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/guidesreports/2018-06-15-cybersecurity-and-risk-advisory-services" target="_blank">Learn more about AHA's Cybersecurity and Risk Advisory Services</a></div> </div> </div> </div> </div> Wed, 01 Jun 2022 14:27:30 -0500 Fraud /lettercomment/2020-06-19-aha-comments-oig-proposed-rule-information-blocking-enforcement <p>AHA comments on the proposed rule on grants, contracts, and other agreements: fraud and abuse; information blocking; Office of Inspector General’s (OIG) civil money penalty (CMP) rules.</p> Fri, 19 Jun 2020 14:34:34 -0500 Fraud /news/headline/2019-05-13-supreme-court-rules-whistleblowers-have-10-years-file-under-fca <p>Whistleblowers who file a lawsuit within three years of reporting an alleged fraud to a responsible government official may have up to 10 years after the alleged fraud occurred to file a lawsuit under the False Claims Act, the Supreme Court ruled today in Cochise Consultancy, Inc. v. United States ex rel. Hunt. Most federal courts have previously said a whistleblower had only six years to file such claims. Today’s ruling could make discovery against government agencies more routine in declined FCA cases, said AHA outside counsel Jonathan Diesenhaus, a partner at Hogan Lovells. “Like the Supreme Court’s Escobar decision two years ago, this new decision underscores how important it is to keep track of what the government knew and when they knew it, because internal government awareness and analysis of a hospital’s complex billing questions could be that hospital’s best defense to allegations of fraud or false claims,” Diesenhaus said.  </p> Mon, 13 May 2019 14:55:22 -0500 Fraud /letter/2019-04-08-aha-oig-proposal-unlikely-lower-drug-prices <p>A Department of Health and Human Services' Office of Inspector General proposal to change drug discount safe harbors under the federal anti-kickback statute would likely increase premiums for Medicare beneficiaries without addressing the nation's high and rising drug prices, the AHA said.</p> Mon, 08 Apr 2019 13:26:52 -0500 Fraud /amicus-brief/2019-02-13-amicus-brief-aha-and-federation-american-hospitals <p>The AHA and Federation of ����������s today urged the U.S. Supreme Court to review a federal appeals court decision that allows False Claims Act whistleblowers to accuse a hospital or other defendant of fraud and proceed to discovery without articulating specific facts demonstrating the circumstances or scope of the alleged fraud.</p> Wed, 13 Feb 2019 14:43:55 -0600 Fraud /news/headline/2018-09-13-house-approves-four-medicare-related-bills <p>The House of Representatives yesterday approved legislation (<a href="https://waysandmeans.house.gov/wp-content/uploads/2018/09/20180905-AINS-to-H.R.-6690-1.pdf">H.R. 6690</a>) that would establish a three-year pilot program to test using smart card technology to combat Medicare fraud and protect beneficiary identity. Also approved were bills that would codify the process by which Medicare administrative contractors make local coverage determinations for their regions (<a href="https://waysandmeans.house.gov/wp-content/uploads/2018/09/20180905-AINS-to-H.R.-3635-2.pdf">H.R. 3635</a>); codify a regulation allowing non-deemed Medicare Cost Plan enrollees to take advantage of the special enrollment period offered to deemed enrollees (<a href="https://waysandmeans.house.gov/wp-content/uploads/2018/09/20180905-AINS-to-H.R.-6662-1.pdf">H.R. 6662</a>); and direct the Department of Health and Human Services to finalize regulations this year for the Program of All-Inclusive Care for the Elderly (<a href="https://waysandmeans.house.gov/wp-content/uploads/2018/09/20180905-AINS-to-H.R.-6561-1.pdf">H.R. 6561</a>). The bills cleared the Ways and Means Committee last week.</p> Thu, 13 Sep 2018 14:42:38 -0500 Fraud /news/headline/2018-09-06-committee-approves-four-medicare-related-bills <p class="CalendarText">The House Ways and Means Committee yesterday approved legislation (<a href="https://waysandmeans.house.gov/wp-content/uploads/2018/09/20180905-AINS-to-H.R.-6690-1.pdf">H.R. 6690</a>) that would establish a three-year pilot program to test using smart card technology to combat Medicare fraud and protect beneficiary identity. The committee also approved legislation that would codify the process by which Medicare administrative contractors make local coverage determinations for their regions (<a href="https://waysandmeans.house.gov/wp-content/uploads/2018/09/20180905-AINS-to-H.R.-3635-2.pdf">H.R. 3635</a>); codify a regulation allowing non-deemed Medicare Cost Plan enrollees to take advantage of the special enrollment period offered to deemed enrollees (<a href="https://waysandmeans.house.gov/wp-content/uploads/2018/09/20180905-AINS-to-H.R.-6662-1.pdf">H.R. 6662</a>); and direct the Department of Health and Human Services to finalize regulations this year for the Program of All-Inclusive Care for the Elderly (<a href="https://waysandmeans.house.gov/wp-content/uploads/2018/09/20180905-AINS-to-H.R.-6561-1.pdf">H.R. 6561</a>). <br /> </p> Thu, 06 Sep 2018 15:26:17 -0500 Fraud /letter/2018-08-03-aha-responds-cmss-rfi-reducing-regulatory-burden-stark-law <div class="container row"> <div class="row"> <div class="col-md-10"> <p class="field_lead">RE: CMS-1720-NC, Request for Information Regarding the Physician Self-referral Law</p> <div><a class="btn btn-primary" href="/system/files/2018-08/180803-letter-stark-rfi.pdf"><i aria-hidden="true" class="fa fa-download"><span class="sr-only">dl icon</span></i>Download the letter (PDF)</a></div> <p> </p> <p>The AHA’s response to the request for information from the Centers for Medicare & Medicaid Services highlights the obstacles hospitals and physicians face in moving to a value-based system while navigating the Stark Law compensation regulations that were built for the very different fee-for-service model. We also recommend specific changes to remove barriers and drive patient-centered care.</p> </div> </div> </div> Fri, 03 Aug 2018 10:53:10 -0500 Fraud /lettercomment/2013-05-13-aha-comment-letter-oig-extending-antikickback-protections-health-it <p>AHA's comments on the Department of Health and Human Services Office of Inspector General’s (OIG) proposed rule that would extend the regulatory protections under the federal antikickback law for hospitals that want to provide assistance to physicians in adopting certain health information technology (IT). We support the agency’s decision to extend the protections, which were scheduled to expire at the end of this year, for at least another three years until Dec. 31, 2016.</p> Mon, 13 May 2013 14:22:18 -0500 Fraud