Write Letter to CMS Administrator Oz Praising CMS Initiatives, Calling for Stable Benchmarks
WASHINGTON — Today, Congressman Vern Buchanan, Vice Chairman of the House Ways and Means Committee and Chair of the Health Subcommittee, and Congressman Morgan Griffith (R-Va.), Chair of the Health Subcommittee on the Energy and Commerce Committee, led a letter to the Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz, asking him to continue strengthening Medicare program integrity while ensuring that accountable care organizations (ACOs) and other value-based care models are not unfairly harmed by fraudulent or inappropriate billing activity.
In their letter, the lawmakers praised CMS’s recent actions under the CRUSH initiative to address rapidly rising spending on products vulnerable to fraud, waste and abuse. They emphasized that ACOs have helped improve patient outcomes and reduce costs for taxpayers by promoting preventive care, chronic disease management and better care coordination.
“We appreciate CMS’s leadership and its ongoing commitment to protecting the Medicare program while advancing innovative models of care,” write Buchanan and Griffith. “We look forward to continued collaboration to ensure that program integrity efforts and accountable care initiatives work in tandem to strengthen Medicare for beneficiaries, providers and taxpayers alike.”
Buchanan and Griffith also expressed concern that unusual billing trends could distort Medicare benchmarking methodologies and create instability for providers participating in accountable care models. The lawmakers encouraged CMS to continue exploring targeted protections for ACOs impacted by high spending categories and to establish guardrails that limit the effect of inaccurate trend calculations on payment benchmarks. They argued that maintaining stable and predictable benchmarks is essential for physicians and providers who invest in care coordination and other services that improve outcomes for Medicare beneficiaries, while also supporting continued participation in innovative value-based care models.
In addition to being the Vice Chairman and most senior Republican on the powerful U.S. House Ways and Means Committee, Buchanan is also the Chairman of the Health Subcommittee, which has broad jurisdiction over traditional Medicare, the Medicare prescription drug benefit program and Medicare Advantage.
Read the full letter here or below.
Dear Administrator Oz:
We write to commend the Centers for Medicare & Medicaid Services (CMS) for its ongoing work to strengthen program integrity across the Medicare program. In particular, we appreciate the agency’s recent actions through the Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) initiative and other efforts to address the rapid growth in spending on skin substitutes and other services that may be vulnerable to fraud, waste, and abuse (FWA). These efforts mark an important shift toward proactive fraud prevention.
As Chairmen of the Energy & Commerce and Ways & Means Health Subcommittees, we have worked for years to strengthen Medicare program integrity, protect Medicare beneficiaries and Medicare-participating health care providers, and support payment models that properly reward high-quality, efficient care.
Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) and other ACO and value-based models offered by the Center for Medicare and Medicaid Innovation (CMMI)—are helping keep Americans healthier while lowering costs for the Medicare program and taxpayers. By equipping clinicians with tools to emphasize prevention, better manage chronic conditions, and coordinate care across settings, ACOs have generated billions in savings for Medicare over the past decade. Clinicians participating in these models consistently outperform traditional fee-for-service providers on quality and cost metrics, while reinvesting shared savings into services that improve outcomes for Medicare beneficiaries.
Clinicians in ACOs are also frequently among the first to identify unusual billing patterns and sudden increases in spending across the Medicare program. We are encouraged by CMS’s recognition that certain products and services, including skin substitutes, have experienced rapid and potentially inappropriate spending growth that is negatively impacting clinicians in accountable care models. CMS’s recent announcement to remove expenditures for certain high-risk categories—such as catheters, dressings, and orthotics—will help protect clinicians from fraudulent spending that has occurred outside of their control.
Specifically, we appreciate the agency’s targeted approach within the ACO REACH model to remove a significant portion of skin substitute expenditures for performance year 2025 and the agency’s commitment to hold ACO REACH participants harmless from any associated downside risk. These actions reflect a thoughtful and responsive approach to emerging program integrity concerns and will help stabilize participation in advanced accountable care models as CMMI launches the new LEAD Model.
As CMS continues implementing these program integrity measures, we encourage ongoing consideration of how these policies intersect with accountable care benchmarks and financial methodologies. While we understand that Medicare’s truncation factor will help mitigate impacts of skin substitute expenditures for many MSSP ACOs, we are concerned that roughly 10 percent of ACOs may still experience significant impact from high spending on skin substitutes. Given that many of these ACOs treat complex and high-needs patient populations, we encourage CMS to continue exploring opportunities to support these ACOs in a targeted and programmatically consistent manner.
In addition, we note that broader spending trends influenced by unusual or inappropriate billing may continue to affect national growth factors used in accountable care model benchmarks. This includes the Accountable Care Prospective Trend (ACPT) in MSSP. We appreciate that, in the prior year, CMS reduced the weight of the ACPT in recognition of methodological concerns, and we thank the agency for acknowledging these issues and taking corrective action. As CMS evaluates lessons learned from recent program integrity actions, we encourage the agency to consider establishing prospective guardrails within ACPT to limit the impact of incorrect trend calculations. In particular, CMS should consider adopting guardrails similar to those outlined in the new LEAD Model that seeks to limit outlier cost growth and spending shocks to improve benchmark stability.
These considerations are particularly important for primary care providers and other clinicians who rely on stable benchmarks to sustain investments in care coordination, patient outreach, and other services that improve outcomes but are not traditionally reimbursed under fee-for-service Medicare. Maintaining a predictable and accurate benchmarking environment will help preserve these investments and support continued participation in accountable care models.
Lastly, we recognize the importance of timeliness and predictability in program integrity actions. As CMS continues to identify and respond to emerging FWA risks, minimizing the lag between the identification of concerning spending patterns and the implementation of corresponding policy adjustments will help reduce uncertainty for participating providers and support sustained engagement in accountable care models.
We appreciate CMS’s leadership and its ongoing commitment to protecting the Medicare program while advancing innovative models of care. We look forward to continued collaboration to ensure that program integrity efforts and accountable care initiatives work in tandem to strengthen Medicare for beneficiaries, providers, and taxpayers alike.
Thank you for your attention to these important issues.
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