By ISSAC SMITH

According to a recent report in the Washington Post, a $3 billion scam involving urinary catheters has brought to light serious flaws in Medicare, prompting strong calls for reform. Apparently, several companies have been accused of gaming the system by submitting fraudulent bills for millions of catheters using patient and doctor information. This isn’t the first time Medicare has faced such challenges; fraudsters often target the system, especially in cases involving unnecessary medical equipment. With a budget nearing $1 trillion, the agency has faced significant challenges in tackling fraudulent claims for durable medical equipment. Leaders at CMS have appealed to Congress for more resources to strengthen their efforts against potential scammers.

Healthcare providers and lawmakers are now pushing for tougher measures to crack down on these companies and improve fraud prevention efforts. The National Association of Accountable Care Organizations (ACOs) has praised CMS for taking steps to address suspicious billing practices related to catheters, underscoring the importance of policy changes to protect against future abuses.

“This is unlike anything we have seen before in terms of its size and scope,” said Clif Gaus from the National Association of Accountable Care Organizations, which played a crucial role in uncovering and drawing attention to the alleged fraud.

Several accountable care organizations (groups of hospitals and doctors) said they could each lose more than $1 million if the fraudulent billing issue isn’t fixed.

In a proposed rule released on Friday, CMS stated that an investigation is currently underway, and that initial steps have been taken in response.

The agency mentioned it has already referred the matter to law enforcement, recovered improper Medicare payments, and removed certain suppliers from the Medicare program. Gaus cautioned that similar schemes are likely to emerge in the future. “These scammers have access to patient IDs, provider IDs, and may even use AI to sift through large volumes of patient data they gather from various sources,” Gaus explained.

It’s not the first time a significant organization has experienced such a breach. This incident marks the second major data breach of 2024, following an earlier breach at Change Healthcare. With the march of technology come both its blessings and its curses.

What You Should Do

Scammers are targeting Medicare beneficiaries with promises of free medical services, equipment, or gift cards via phone calls, online ads, and text messages. They entice people by offering “no-cost” or “free” items once personal details and Medicare eligibility are confirmed. After obtaining personal information, scammers may start billing Medicare monthly for unnecessary urinary catheters, sometimes without even delivering them.

Typically, the scam begins with a deceptive durable medical equipment (DME) company contacting the beneficiary, claiming affiliation with Medicare. They aim to acquire the Medicare number.

Often, the DME company will find a healthcare provider, who may not have any connection to the beneficiary, to sign off on DME authorizations. Occasionally, they may coerce the beneficiary’s own provider into signing.

The HHS Office of Inspector General (HHS-OIG) urges the public to stay vigilant and report any suspicious activities to the HHS-OIG Hotline at 1-800-HHS-TIPS. By reporting tips and complaints, HHS-OIG can investigate and take action against fraud, safeguarding Medicare beneficiaries and federal healthcare programs.

What the Future Holds

The Medicare catheter scam has brought to light serious vulnerabilities within the Medicare system, posing potential financial risks for both beneficiaries and Accountable Care Organizations (ACOs):

• For Beneficiaries:

This scam may lead to monthly charges for unnecessary catheters that might never be received. If personal information is compromised, it could also be exploited for other fraudulent activities.

• For ACOs:

The fraudulent billing could raise per capita costs for beneficiaries linked to an ACO, potentially diminishing the shared savings that ACOs aim to achieve. Moreover, these erroneous payments could influence benchmark calculations for future periods.

The Government Accountability Office (GAO) highlighted some key findings in its recent study on CMS vulnerabilities. They suggested that implementing fingerprint-based criminal background checks for high-risk providers who enrolled without them could help catch those who might have provided false information during their enrollment.

Additionally, GAO emphasized the importance of regularly revalidating provider enrollments, especially for high-risk or moderate-risk provider types. This would ensure that only eligible providers deliver Medicare services.

Following investigations, CMS will implement new policies or tighten existing ones to prevent future abuse. This could include stricter documentation requirements, more frequent audits, or changes in reimbursement rates for medical billing.

Providers implicated in scams may face penalties, fines, or exclusion from Medicare and other federal healthcare programs. For patients, stricter policies could mean changes in the availability or coverage of medical supplies, potentially affecting patient care and choices.

Over time, such incidents often lead to improvements in Medicare’s fraud detection systems and policies. However, there might also be unintended consequences, such as an increased administrative burden for legitimate providers or changes in patient access to certain medical products.

The Bottom Line

Patients and healthcare providers are wondering how they can stop Medicare fraud in the future, given that it’s a big problem.

Jason Jobes from Norwood Staffing is worried that smaller ACOs might not have the right tools and expertise to catch fraudsters, which could hit them hard financially. He suggests that specialized vendors could help these ACOs manage their costs better and detect any wrongdoing, even though it might be costly. Jobes advises ACOs to closely monitor how they use medical codes and compare these with previous years to spot any unusual patterns.

There’s also concern about some organizations possibly turning a blind eye to fraud risks related to Medicare claims. NAACOS, a healthcare group, wants the government to pay more attention to fraud reports from ACOs and work with Medicare to improve how they report suspicious activities.

Jobes also worries that too many rules could slow down legitimate claims processing and hurt healthcare providers financially. He thinks it’s crucial to strike a balance between preventing fraud and ensuring that providers can manage their finances properly.

NAACOS is also looking into concerns about how diabetic supplies and skin grafts are being used, wondering if similar issues might affect other medical products in the future. Let’s see what happens next in this advanced technological era!

Issac Smith is medical billing and coding, and compliance specialist who works for Medcare MSO