“We’ve never seen anything like this” in size and scope, said one industry leader.
Federal officials are seeking to overhaul how Medicare pays health-care providers after an alleged $3 billion scheme to defraud the program, which would be one of the largest such schemes in its history.
“We’ve never seen anything like this” in size and scope, said Clif Gaus, CEO of the National Association of Accountable Care Organizations, which helped uncover and spotlight the alleged fraud earlier this year. 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.
“We have made referrals to law enforcement, recouped improper Medicare payments, and terminated certain suppliers from the Medicare program,” the agency added in its proposed rule. CMS also said it would change its payment formula for accountable care organizations, citing the surge of “significant, anomalous and highly suspect” bills linked to urinary catheters. The change effectively protects the organizations from the spike in catheter bills.
“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.Patients drawn into the alleged fraud said they remain confused and nervous about the implications of fraudsters knowing their personal information.
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