News report on healthcare billing fraud prompts senators' call for federal action

Kelly Gooch - Print  | 

Six U.S. senators are seeking more information about CMS efforts to combat healthcare fraud, waste and abuse after a recent media report that followed the scam of a Texas personal trainer and detailed how such scams are possible, according to Vox.

In July, ProPublica and Vox reported how David Williams was able to submit fraudulent bills with insurance companies Aetna, Cigna and UnitedHealthcare, even though he did not have legitimate medical credentials. The report detailed how the Texas personal trainer went about the scam, which started when Mr. Williams obtained fake national provider identifier numbers through CMS.

According to Vox, ProPublica learned that credentials of medical providers who apply for these numbers go unchecked, and this allows scammers, such as Mr. Williams, to obtain fake national provider identifier numbers and fraudulently bill insurers.

ProPublica and Vox reported that in the case of Mr. Williams' scam, insurers allowed fraud to continue for years, primarily unchecked, and did not confirm the Texas personal trainer's medical credentials. Overall, Aetna, Cigna and UnitedHealthcare, which did not comment to Vox, paid more than $4 million over four years for false claims to Mr. Williams, who was ultimately sentenced for healthcare fraud.

The six U.S. senators — Catherine Cortez Masto of Nevada; Maggie Hassan of New Hampshire; Michael Bennet of Colorado; Sheldon Whitehouse of Rhode Island; Tammy Duckworth of Illinois; and Bob Menendez of New Jersey — spoke out against CMS actions related to the scam.

"CMS' failure not only to flag bad actors, but also to respond appropriately to repeated notices of fraudulent behavior ultimately harmed covered patients," they wrote in a letter to federal regulators that was cited by Vox.

"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," the senators said.

The senators asked federal regulators to answer six questions related to the issue by Sept. 9.


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