March 30, 2026
Re: Request for Information; Related to Comprehensive Regulations to Uncover Suspicious Healthcare (CMS-6098-NC)
Accountable for Health (A4H) appreciates the opportunity to provide comments on the Request for Information (RFI) Related to Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH). We applaud the Administration for its strong commitment to program integrity, including the skin substitutes payment reforms put in place for CY 2026 as well as the more proactive, forward-looking policies and initiatives referenced in this RFI.
As a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care, A4H’s members are often the first to detect suspicious and fraudulent health care billing – as demonstrated recently during the catheter and skin substitutes crises. Our members are accountable for total cost and quality of care and, as such, they are constantly evaluating and analyzing billing and utilization patterns to ensure they are consistent with clinically appropriate care. They have a unique incentive to detect unusual spending patterns and act quicky to protect patients.
For example, in response to the recent skin substitutes crisis, accountable care providers across the country:
- Flagged suspicious billing and escalated cases to CMS and law enforcement.
- Launched wound care programs that emphasize evidence-based care.
- Educated clinicians and patients to prevent unnecessary or harmful procedures.
As outlined in more detail below, A4H strongly recommends that CMS better leverage accountable care participants as front line identifiers of potential fraud, waste, and abuse (FWA) by creating a rapid reporting pathway so providers can share fraud data in real time; 2) take quick action to investigate and resolve complaints of suspected FWA; and 3) take additional steps as needed to ensure that honest clinicians are not punished for others’ abuse and that Medicare remains sustainable and accountable including adjusting benchmarks to reflect targeted cost spikes that national trends miss, protecting model and program participants from catastrophic costs through improved stop-loss policies, and allowing reopening of financial settlements and recoupment of funds when fraudulent claims are later proven.
Role of Accountable Care in Detecting Suspicious and Fraudulent Health Care Billing
Accountable care was created to reduce unnecessary costs in Medicare by aligning providers’ financial incentives with patient outcomes. A central part of that mission is helping the federal government identify and reduce waste, fraud, and abuse. Unlike traditional fee-for-service Medicare, ACOs are rewarded for delivering high-value care, which gives them strong reasons to spot inappropriate spending and redirect resources toward services that benefit patients. This aligns directly with the Centers for Medicare and Medicaid Services’ (CMS) stated goal of protecting the Medicare Trust Fund while improving beneficiary care.
Medicare’s recent experience with skin substitutes illustrates both the opportunities and challenges of this approach, which has seen spending exploded nearly 40-fold to more than $10 billion last year. Accountable care providers quickly identified how a broken payment system was fueling profiteering and patient harm. They elevated these concerns to CMS, deployed care management to address them, and demonstrated the very promise of accountable care: rooting out fraud and abuse while improving health outcomes. Yet current policy gaps still leave providers vulnerable to financial accountability when fraud occurs outside their control.
A4H members are well-equipped to adjust care delivery and networks to combat waste. Unlike unmanaged fee-for-service, providers participating in accountable care constantly monitor claims feeds on their assigned patients to identify gaps in care and unusual spending patterns, and adjust resources to correct those gaps or patterns. For example, ACOs have deployed care management techniques, educated their patients and providers about the challenges of skin substitutes and their referral patterns, and established their own wound care services in certain cases to ensure high-quality care.
Accountable care entities are also regularly reporting fraudulent behavior and abnormal care patterns to federal and state authorities for investigation and resolution. Some of these reports have led to significant recoveries. In late 2023, they were some of the first to identify what became a $10 billion fraud scheme involving urinary catheters. Earlier this year, the Justice Department announced its largest ever healthcare fraud case – valued at more than $14 billion – in a nationwide investigation known as “Operation Gold Rush,” that involved the very urinary catheter fraud ACOs identified.
RFI Comments
What changes could CMS or its contractors make to existing processes to promote their ability to effectively deter fraud, waste, and abuse and promote payment accuracy and efficiency, including by more expeditiously gathering actionable information?
ACOs in traditional Medicare notably lack the tools that private payers possess, including network restrictions, prior authorization, and strict coverage criteria. Accountable care in traditional Medicare allow patients to receive services from any Medicare-enrolled provider, whether that provider works with the ACO or not. Traditional Medicare also does not have strict coverage criteria, and other restrictions are typically prohibited. This means, while providers participating in accountable care may quickly uncover fraud, waste and abuse, their ability to stop payments to a particularly concerning provider are limited.
CMS Should Better Leverage Accountable Care Providers as Front Line Identifiers of FWA
A rapid reporting pathway would enable providers to serve as real-time partners to the Centers for Medicare & Medicaid Services in identifying and addressing fraud, waste, and abuse (FWA).
Given their access to near real-time claims data, care patterns, and provider behavior, ACOs are often the first to detect unusual utilization trends, billing anomalies, or emerging schemes. Establishing a streamlined, standardized mechanism for ACOs to quickly flag and transmit these concerns—paired with clear feedback loops and protections for good-faith reporting—would allow CMS and its program integrity contractors to intervene earlier, limit improper payments, and prevent the spread of abusive practices. By formalizing this pathway, CMS can better leverage ACOs’ on-the-ground insights while reinforcing accountability across the value-based care ecosystem.
CMS Should Take Quick Action When Suspected FWA Is Reported
Actionable information about suspect billing often emerges at the care delivery level before it is visible through traditional program integrity processes. However, there are currently limited pathways for providers to communicate this information in a way that results in timely action.
CMS could take steps to make it easier for communicate potential fraud between accountable care participants and CMS, for CMS to take immediate action, and to ensure that accountable care providers are not being held accountable for true fraud. CMS could strengthen its existing authorities by ensuring that payment suspension tools can be used when there is a reliable indication of overutilization or clinically inappropriate care, in addition to clear fraud – and communicate about claims suspensions to ACOs. Earlier intervention in these cases would help prevent continued billing while investigations are underway and reduce exposure to inappropriate spending. More expeditious action in response to credible signals would help reduce ongoing exposure to inappropriate billing and improve payment accuracy and efficiency.
Additionally, CMS should encourage and allow accountable care participants to join the Healthcare Fraud Prevention Partnership. Today, health plans participate in a robust exchange of information about suspected fraud, including identifying potentially fraudulent providers and sharing evidence in a secure portal. Yet, these tools have not been widespread in the provider community. Today, accountable care participants are prepared to population and share the same information as many plans. CMS should simplify the sign up process, educate accountable care entities about the opportunity, and encourage their active participation.
CMS Should Take Additional Steps to Ensure Participants in Accountable Care Are Not Penalized for Fraud Outside of their Control
There are several concrete actions policymakers can take to help ACOs continue to fulfill their promise of identifying and rooting out fraud, waste, and abuse.
- CMS should adjust ACO benchmarks to account for targeted spending spikes that trend adjustments or other existing policies are failing to capture. In 2024, CMS established the significant anomalous and highly suspect claims (SAHS) policy, which defines thresholds for when the policy applies (e.g., national scope and impact) and specifies actions when such claims are identified (e.g., removing spending from benchmark construction, trend adjustments and performance year costs). While this policy is important, it is broad in scope and has only been applied to the catheter circumstance to date.
- CMS should allow additional time to “reopen” ACOs’ financial settlement so that fraudulent claims can be removed from their financial accountability and modify the reopening process to make it meaningful for providers – for example by creating presumptions for reopening in certain cases or allowing reopening on the basis of a credible assertion of fraud (rather than requiring an overpayment determination). CMMI model participants and Medicare Shared Savings Program (MSSP) participants should be able to re-open their settlements from two or three years prior if criminal proceedings are initiated against potentially fraudulent providers. This longer re-opening period would help account for the timing of Department of Justice and OIG investigations, which can take multiple years. In addition, CMS must offer additional tools to support reopening to ensure that reopening is meaningful and not only available when fraud has been prosecuted successfully.
- CMS should revise stop-loss protections. CMS removes all claims above the 99th percentile of spending for participants of the Medicare Shared Savings Program. Most wound care cases surpass that threshold. CMS offers a stop-loss program to protect some model participants from catastrophic costs for individual patients by covering spending above a certain threshold. In some circumstances, participants can opt into CMS’ option or purchase private stop-loss protection. However, in 2025, virtually no private brokers offered affordable stop-loss coverage if the coverage included skin substitute spending— most simply excluded it. This reflects a broken market and a serious gap.
******
Accountable for Health appreciates the opportunity to provide feedback on this RFI. Please do not hesitate to contact Mara McDermott, mmcdermott@accountableforhealth.org if we can be a resource.
Sincerely,
Mara McDermott
CEO
Accountable for Health
Dr. Mehmet Oz
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services (HHS)
Attention: CMS-6098-NC, Mail Stop C4–26–05
7500 Security Boulevard
Baltimore, MD 21244–1850
March 30, 2026
Re: Request for Information; Related to Comprehensive Regulations to Uncover Suspicious Healthcare (CMS-6098-NC)
Accountable for Health (A4H) appreciates the opportunity to provide comments on the Request for Information (RFI) Related to Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH). We applaud the Administration for its strong commitment to program integrity, including the skin substitutes payment reforms put in place for CY 2026 as well as the more proactive, forward-looking policies and initiatives referenced in this RFI.
As a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care, A4H’s members are often the first to detect suspicious and fraudulent health care billing – as demonstrated recently during the catheter and skin substitutes crises. Our members are accountable for total cost and quality of care and, as such, they are constantly evaluating and analyzing billing and utilization patterns to ensure they are consistent with clinically appropriate care. They have a unique incentive to detect unusual spending patterns and act quicky to protect patients.
For example, in response to the recent skin substitutes crisis, accountable care providers across the country:
As outlined in more detail below, A4H strongly recommends that CMS better leverage accountable care participants as front line identifiers of potential fraud, waste, and abuse (FWA) by creating a rapid reporting pathway so providers can share fraud data in real time; 2) take quick action to investigate and resolve complaints of suspected FWA; and 3) take additional steps as needed to ensure that honest clinicians are not punished for others’ abuse and that Medicare remains sustainable and accountable including adjusting benchmarks to reflect targeted cost spikes that national trends miss, protecting model and program participants from catastrophic costs through improved stop-loss policies, and allowing reopening of financial settlements and recoupment of funds when fraudulent claims are later proven.
Role of Accountable Care in Detecting Suspicious and Fraudulent Health Care Billing
Accountable care was created to reduce unnecessary costs in Medicare by aligning providers’ financial incentives with patient outcomes. A central part of that mission is helping the federal government identify and reduce waste, fraud, and abuse. Unlike traditional fee-for-service Medicare, ACOs are rewarded for delivering high-value care, which gives them strong reasons to spot inappropriate spending and redirect resources toward services that benefit patients. This aligns directly with the Centers for Medicare and Medicaid Services’ (CMS) stated goal of protecting the Medicare Trust Fund while improving beneficiary care.
Medicare’s recent experience with skin substitutes illustrates both the opportunities and challenges of this approach, which has seen spending exploded nearly 40-fold to more than $10 billion last year. Accountable care providers quickly identified how a broken payment system was fueling profiteering and patient harm. They elevated these concerns to CMS, deployed care management to address them, and demonstrated the very promise of accountable care: rooting out fraud and abuse while improving health outcomes. Yet current policy gaps still leave providers vulnerable to financial accountability when fraud occurs outside their control.
A4H members are well-equipped to adjust care delivery and networks to combat waste. Unlike unmanaged fee-for-service, providers participating in accountable care constantly monitor claims feeds on their assigned patients to identify gaps in care and unusual spending patterns, and adjust resources to correct those gaps or patterns. For example, ACOs have deployed care management techniques, educated their patients and providers about the challenges of skin substitutes and their referral patterns, and established their own wound care services in certain cases to ensure high-quality care.
Accountable care entities are also regularly reporting fraudulent behavior and abnormal care patterns to federal and state authorities for investigation and resolution. Some of these reports have led to significant recoveries. In late 2023, they were some of the first to identify what became a $10 billion fraud scheme involving urinary catheters. Earlier this year, the Justice Department announced its largest ever healthcare fraud case – valued at more than $14 billion – in a nationwide investigation known as “Operation Gold Rush,” that involved the very urinary catheter fraud ACOs identified.
RFI Comments
What changes could CMS or its contractors make to existing processes to promote their ability to effectively deter fraud, waste, and abuse and promote payment accuracy and efficiency, including by more expeditiously gathering actionable information?
ACOs in traditional Medicare notably lack the tools that private payers possess, including network restrictions, prior authorization, and strict coverage criteria. Accountable care in traditional Medicare allow patients to receive services from any Medicare-enrolled provider, whether that provider works with the ACO or not. Traditional Medicare also does not have strict coverage criteria, and other restrictions are typically prohibited. This means, while providers participating in accountable care may quickly uncover fraud, waste and abuse, their ability to stop payments to a particularly concerning provider are limited.
CMS Should Better Leverage Accountable Care Providers as Front Line Identifiers of FWA
A rapid reporting pathway would enable providers to serve as real-time partners to the Centers for Medicare & Medicaid Services in identifying and addressing fraud, waste, and abuse (FWA).
Given their access to near real-time claims data, care patterns, and provider behavior, ACOs are often the first to detect unusual utilization trends, billing anomalies, or emerging schemes. Establishing a streamlined, standardized mechanism for ACOs to quickly flag and transmit these concerns—paired with clear feedback loops and protections for good-faith reporting—would allow CMS and its program integrity contractors to intervene earlier, limit improper payments, and prevent the spread of abusive practices. By formalizing this pathway, CMS can better leverage ACOs’ on-the-ground insights while reinforcing accountability across the value-based care ecosystem.
CMS Should Take Quick Action When Suspected FWA Is Reported
Actionable information about suspect billing often emerges at the care delivery level before it is visible through traditional program integrity processes. However, there are currently limited pathways for providers to communicate this information in a way that results in timely action.
CMS could take steps to make it easier for communicate potential fraud between accountable care participants and CMS, for CMS to take immediate action, and to ensure that accountable care providers are not being held accountable for true fraud. CMS could strengthen its existing authorities by ensuring that payment suspension tools can be used when there is a reliable indication of overutilization or clinically inappropriate care, in addition to clear fraud – and communicate about claims suspensions to ACOs. Earlier intervention in these cases would help prevent continued billing while investigations are underway and reduce exposure to inappropriate spending. More expeditious action in response to credible signals would help reduce ongoing exposure to inappropriate billing and improve payment accuracy and efficiency.
Additionally, CMS should encourage and allow accountable care participants to join the Healthcare Fraud Prevention Partnership. Today, health plans participate in a robust exchange of information about suspected fraud, including identifying potentially fraudulent providers and sharing evidence in a secure portal. Yet, these tools have not been widespread in the provider community. Today, accountable care participants are prepared to population and share the same information as many plans. CMS should simplify the sign up process, educate accountable care entities about the opportunity, and encourage their active participation.
CMS Should Take Additional Steps to Ensure Participants in Accountable Care Are Not Penalized for Fraud Outside of their Control
There are several concrete actions policymakers can take to help ACOs continue to fulfill their promise of identifying and rooting out fraud, waste, and abuse.
******
Accountable for Health appreciates the opportunity to provide feedback on this RFI. Please do not hesitate to contact Mara McDermott, mmcdermott@accountableforhealth.org if we can be a resource.
Sincerely,
Mara McDermott
CEO
Accountable for Health
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