Federal officials are seeking to overhaul how Medicare pays health-care providers after an alleged $3 billion scheme to defraud the program, one of the largest such schemes in its history. For more than a year, about a dozen companies submitted bills to the Centers for Medicare and Medicaid Services (CMS) for tens of millions of urinary catheters, using the personal information of Medicare beneficiaries and physicians — some of whom question how the companies obtained their private details and used them to bill the federal health program for catheters that they never wanted nor received, reports the Washington Post. Experts said the catheter fraud ring is a reminder that Medicare is a tempting target for scammers. The roughly $1 trillion agency has struggled to combat a stream of fraudulent claims for durable medical equipment. CMS leaders have urged Congress to provide them with additional resources to crack down on would-be thieves.
Health-care providers urged the government to clamp down on the companies, saying the scheme threatened to distort Medicare payments by making it appear that doctors were ordering massive amounts of unnecessary catheters and skewing the government’s formula for reimbursing providers. "We’ve never seen anything like this” in size and scope, said Clif Gaus of the National Association of Accountable Care Organizations, which helped uncover and spotlight the alleged fraud. Several accountable care organizations — groups of hospitals and physicians that receive federal incentives to deliver high-quality, low-cost health care — said they could each lose more than $1 million in payments if the fraudulent bills were not addressed.
In a proposed rule issued Friday, CMS said an investigation was “ongoing, and we have taken initial actions in response.” “We have made referrals to law enforcement, recouped improper Medicare payments, and terminated certain suppliers from the Medicare program,” the agency said. Gaus warned that similar schemes are likely on the horizon. “These fraudsters can get patient IDs, provider IDs, and maybe use AI to glean through these massive files of patient data that they collect from everywhere,” Gaus said.
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