The Blue Cross Blue Shield Association submitted a wide-ranging letter to CMS on March 30 in response to the agency’s information request on its Comprehensive Regulations to Uncover Suspicious Healthcare, or CRUSH, initiative.
Seven BCBSA recommendations:
1. CMS should notify Medicare Advantage plans in real time when it suspends payments to a provider over suspected fraud because bad actors are exploiting the current information gap by shifting billing from original Medicare to MA after CMS acted on suspected fraud in fee-for-service.
2. CMS should remove any contractual or policy language that requires MA plans to continue paying claims when fraud is suspected, regardless of whether CMS has paid its portion. The association also recommends that suspect claims be tagged with a unique code or priced at zero member liability at the time of a CMS payment suspension, so MA plans can identify those claims before payment.
3. On the question of whether MA plans should have mandatory payment suspension authority similar to original Medicare, BCBSA urged caution. The association said MA plans currently lack the internal infrastructure for rapid and accurate suspensions, and that a direct application of the original Medicare framework might not work given MA’s capitated payment structure and provider contract obligations. BCBSA recommends a phased pilot before anything permanent.
4. CMS should require testing and verification of any AI tool used in MA coding oversight before deployment and at regular post-deployment intervals. BCBSA also recommends that entities deploying these tools establish internal AI governance programs and that developers be required to disclose facts about tool design, training data, and known limitations through a standardized disclosure framework.
5. If CMS deploys AI for RADV audits, the association says the technology should serve only as decision support and not replace qualified clinical and coding professionals in making diagnosis validation or payment recovery decisions. The association also recommends that AI-supported RADV workflows be set up to detect both overpayments and underpayments, and that CMS publish performance metrics. Insurers should be able to review and appeal AI-assisted findings.
6. Overall, the association says the independent dispute resolution process under the No Surprises Act is broken and needs structural fixes. BCBSA recommends CMS launch the IDR Gateway as soon as possible, implement baseline eligibility screening before payment or review, establish an upfront eligibility fee to deter bad-faith submissions, and create performance metrics.
7. CMS should require non-participating durable medical equipment suppliers to meet original Medicare accreditation and enrollment standards as a condition of billing MA plans. BCBSA also recommends CMS establish a central registry of non-participating DMEPOS suppliers that MA plans can screen against before processing claims.
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