Medicare Payment Reform for Skin Substitutes and Enhanced Fraud Control.
This Act reforms Medicare payment rules to ensure consistent coverage and access to advanced skin substitute products used for wound care. It establishes a new, standardized payment method based on historical volume-weighted averages, aiming to stabilize costs within the system. Crucially, it introduces strict program integrity measures, including identifying and scrutinizing the highest-billing providers to combat fraud and waste.
Key points
Medicare Part B coverage is explicitly extended to include defined skin substitute products, improving access to advanced wound treatment for beneficiaries.
A new, standardized payment rate for these products, adjusted annually for inflation (CPI-U), will take effect starting January 1, 2026.
The government will identify the top 3% of providers receiving the highest payments ("outlier providers") and subject their claims to prepayment review or mandatory prior authorization to prevent billing abuse.
Providers with high denial rates (over 75%) for prior authorization requests may face exclusion from the Medicare program, enhancing service quality and integrity.
Introduced
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