August 14, 2019

Cortez Masto Leads Letter to HHS Demanding Answers on How Agency is Combating Health Care Fraud

Washington, D.C. – U.S. Senator Catherine Cortez Masto (D-Nev.) led a letter to Health and Human Services (HHS) Secretary Alex Azar and Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma demanding more information about efforts by CMS to address fraud, waste and abuse in the health care system. Recent articles have indicated that CMS has systematically failed to stem fraud, even when the fraud is properly flagged by individuals with knowledge of the circumstances. The letter requests detailed information on what actions CMS is taking to strengthen security and consumer protection in light of this report.

“We must work to close loopholes and gaps in our system that allow bad actors to defraud insurers and patients, especially if they are covered by health programs supported by taxpayers,” said the Senators. “Commercial health plans and their enrollees depend on the validity of federal provider identification systems in order to ensure that patients’ dollars are well spent.”

In addition to Senator Cortez Masto, U.S. Senators Bob Menendez (D-N.J.), Sheldon Whitehouse (D-R.I.), Michael Bennet (D-Colo.), Maggie Hassan (D-N.H.) and Tammy Duckworth (D-Ill.) also cosigned this letter.

A full copy of the letter can be found HERE and below:

Dear Secretary Azar and Administrator Verma:

We write today to ask for more information about the Centers for Medicare and Medicaid Service’s (CMS) efforts to address fraud, waste, and abuse in light of a recent news report by ProPublica of systemic failures to stem fraud, even when properly flagged by individuals with knowledge of the circumstances.

On July 19, 2019, ProPublica reported that one such case began with an individual obtaining a fraudulent National Provider Identifier (NPI) through CMS. The private insurance companies then neglected to review a high number of out-of-network claims from that provider number. As a result, United, Aetna, and Cigna paid $4 million for false claims to a provider that had no medical license. Moreover, CMS’s failure not only to flag bad actors, but also to respond appropriately to repeated notices of fraudulent behavior ultimately harmed covered patients.

We must work to close loopholes and gaps in our system that allow bad actors to defraud insurers and patients, especially if they are covered by health programs supported by taxpayers. Commercial health plans and their enrollees depend on the validity of federal provider identification systems in order to ensure that patients’ dollars are well spent.

We would like to work with you to identify what additional authority CMS needs to preserve program integrity as well as what actions CMS is taking to address security gaps in light of this report. To that end, we request answers to the following questions in writing by September 9, 2019.

  1. What measures has CMS taken to strengthen the requirements for obtaining a National Provider Identifier (NPI)?
  2. Is CMS able to coordinate with the U.S. Department of Treasury to link NPI numbers and tax identification numbers to flag fraud?
  3. Does CMS regularly review NPI numbers that have unusual billing practices or claims? If so, how often do they conduct these reviews?
  4. What processes does CMS have in place to respond to claims of possible NPI fraud?
  5. Has CMS received similar reports of potentially fraudulent Medicare billing practices by bad actors posing as doctors providing medical services?
  6. What program requirements exist to hold insurance companies participating in Medicare accountable for failure to respond to fraud?

a. If such requirements don’t exist, is additional statutory authority needed for CMS to exercise sufficient pressure to incentivize insurance companies to perform better fraud review?

We look forward to hearing from you and to working together to address this matter and ensuring CMS’s active role in addressing fraud in the health system.

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