CEO at mimilabs | CTO at falcon | LinkedIn Top Voice | Ph.D., Machine Learning and Health Data
ACO Leaders: Remember UTI Catheter A4352 and A4353? They're Still Active in CY2024! 📊 Quick Check Needed: Run your CY2024 CCLF data for these two catheter codes. While CMS removed them from shared savings calculations for CY2023, the January-February 2024 claims are still included in your benchmark and performance year calculations. What We're Seeing: 1. High billing activity continued through January-February 2024 2. Sudden stop after the Washington Post article (classic sentinel effect!) The Background You Know: The Washington Post's February 2024 investigation [1] exposed the DME fraud scheme we've all been tracking. The Centers for Medicare & Medicaid Services responded by creating the "Significant, Anomalous, and Highly Suspect (SAHS)" classification and removed these claims - but only for CY2023. Why This Matters Now: The CY2025 PFS final rule [3] specifically states: "Establish an approach to identify SAHS billing activity occurring in CY 2024 or subsequent calendar years, and specify approaches to mitigating the impact of the SAHS billing activity on Shared Savings Program financial calculations in CY 2024 or subsequent calendar years. Under this approach we will exclude payment amounts from expenditure and revenue calculations for the relevant calendar year for which the SAHS billing activity is identified, as well as from historical benchmarks used to reconcile the ACO for a performance year corresponding to the calendar year for which the SAHS billing activity is identified." Let's Take Action: If you see the same pattern, join us! falconhealth.ai is compiling supporting materials for CMS to address these early 2024 claims. Share your findings in the comments or DM us (me and Neil Ahuja) - let's get these claims addressed for CY2024. Let's get this removed from the expenditure!! #Medicare #ACO #MSSP #ACOReach #ProgramIntegrity [1] https://lnkd.in/e5dwvmdX [2] https://lnkd.in/eHjtNCAn [3] https://lnkd.in/euTdTynB
My team actually flagged this for some of our ACOs, and I had put in a ticket with CMS about it last week. I received feedback that they believe they have already removed the anomalous claims from 2024, even though we can see them in our quarterly benchmark files. We'll continue pushing back, but it could definitely make the difference for us.
Explorer, MD, PhD | Physician, Scientist, Clinical Informatics, AI, ML | CMO, VP, Board Member | Diversity & Health
3wcan i share a controversial take? i wonder how much technique of catheter placements influencers rates of catheter associated UTIs, this acronym CAUTI i am most used to has changed over decades it is done by nursing, but also you are forced to do it a handful of times as a medical student for punishment. it is supposed to be done sterilely, but physicians (especially surgeons) have no clue what sterile means, everything is "semi-sterile", if you ever do cell culture as a scientist or work in a BSL-3 facility then you learn what sterile actually means in other words, and maybe someone has done this, are there any correlations out there between changes in policy (i doubt this simple procedure has changed much in decades) and infections? to be very frank, i do not believe people are getting "urosepsis" because someone supposedly "contaminated" a catheter, many people would disagree, but when i ask them based on what, there is never a good answer i could ask the same of central lines, arterial lines are not placed using same the "intense" "sterile" protocols, why? made up in the 1970s...