It has taken months for me to understand that the immediate threat from CTP/skin sub over/improper use is to Accountable Care Organizations (ACOs). I’ve blogged previously about why. An ACO that asked not to be named gave me the following figures around CTP billing in their organization: “In 2021 & 2022 we saw ~ $1M in payment for CTPs each year. In 2023 it increased to $7M, and through only the first half of 2024 it’s increased to $12M+.”
That is the spend for ONE ACO. Those numbers are totally unsustainable. However, ACOs have some recourse to combat fraud. The Centers for Medicare & Medicaid Services (CMS) finalized a rule to limit the impact of fraudulent billing activity on the finances of accountable care organizations (PDF). The rule tackles what are called “significant, anomalous and highly suspect” (SAHS) billing activity and its impact on Medicare Shared Savings Program (MSSP) financial calculations. The particular focus of the ACOs for the recent CMS rule was around $2B in possibly fraudulent Medicare charges for urinary catheters.
However, the ACO spend on urinary catheters may be nothing compared to the possibly fraudulent billing for CTPs. I am sure the ACOs, like everyone else, are waiting anxiously to find out whether the proposed LCD(s) for CTPs will be finalized. It will be interesting to find out whether the National Association of ACOs (NAACOS) and the survival of the Medicare Shared Savings Program will be able to withstand the lobbying efforts of a multi-billion-dollar skin sub industry that is focused on stopping the LCDs.
This little comment in the Medicare physician fee schedule final rule is worth noting. SAHS billing activity for CTPs threatens the MSSP, and skin subs are part of the reason. Skin sub over-users and manufacturers should be saying, “WTF!” Which I will translate as, “Wait on that Ferrari.”
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
