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Around the nation: CMS proposes new ACO rule after $3B fraud scheme


CMS has issued a new proposed rule for accountable care organizations (ACOs) following an alleged $3 billion fraud scheme involving urinary catheters, in today's bite-sized hospital and health industry news from Illinois, Georgia, and Maryland.  

  • Illinois: Modern Healthcare has named Kim Keck, president and CEO of the Blue Cross Blue Shield Association (BCBSA), the inaugural winner of its Women Leaders Vanguard Award. Keck is the first woman to serve as president and CEO of BCBSA. During her tenure, she has worked to foster diversity and support women through programs like "Break into the Boardroom," which is designed to encourage equal representation in governance across the healthcare industry. Keck has also been vocal about using BCBSA's reach to reduce health disparities, especially for maternal health, and has made care affordability a central goal. According to Modern Healthcare, Keck will discuss her career and the path to leadership for women in healthcare during the 14th annual Women Leaders in Healthcare Conference and Awards Luncheon, which will take place in Chicago on July 16. (Modern Healthcare, 6/17)
  • Georgia: Last month, CDC Director Mandy Cohen endorsed new recommendations for updated COVID-19 and flu vaccines for the fall following a meeting of the agency's Advisory Committee on Immunization Practices (ACIP). During the meeting, ACIP members voted 11-0 to recommend that everyone ages six months and older receive an updated COVID-19 vaccine. The committee also unanimously voted to recommend that everyone ages six months and older receive an updated 2024–2025 flu vaccine, with some rare exceptions. In a final unanimous vote, the committee recommended that a new 21-valent pneumococcal vaccine be an option for adults ages 19 years and older who are recommended to receive a dose. According to James Loehr, chair of the Pneumococcal Vaccines Work Group, current recommendations for pneumococcal vaccines are "just confusing." Because of this, ACIP will revisit the issue of pneumococcal vaccines during their October 2024 meeting. (Kahn, MedPage Today, 6/28)
  • Maryland: CMS recently issued a new proposed rule for ACOs following an alleged $3 billion fraud scheme involving urinary catheters. According to federal officials, around a dozen companies submitted bills to CMS for tens of millions of urinary catheters for more than a year by using the personal information of Medicare beneficiaries and physicians. Overall, 11 companies were responsible for $3.16 billion in suspect bills for urinary catheters between January 2023 and March 2024, but CMS was able to successfully block the payments. In the proposed rule, payment amounts for certain intermittent urinary catheters submitted from suppliers would be excluded from performance assessments for Medicare Shared Savings Program ACOs for 2023. Benchmarks will also be set for 2024, 2025, and 2026. Clif Gaus, president and CEO of the National Association of ACOs, said his organization "applauds CMS for implementing stakeholder recommendations to hold ACOs harmless for significant anomalous and highly suspect catheter expenditures in 2023" and that the proposed rule "ensures that clinicians, hospitals, other healthcare providers and ACOs can remain in the models and are not unfairly penalized." (Tong, Fierce Healthcare, 7/1; Diamond/Weber, Washington Post, 7/2)

C-SUITE CHEAT SHEET: FRAUD AND ABUSE

Download our cheat sheet to learn about fraud and abuse regulations, how to guard against potential violations, and prepare to have conversations with health system executives about compliance programs.


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