Leading Republicans in the House are demanding answers regarding a recently uncovered catheter billing scheme that has critical implications for Medicare and accountable care organizations.
In a new letter (PDF), lawmakers are instructing the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) to answer for an alleged $2 billion fraud scheme involving at least seven durable medical equipment companies by March 20. The request comes from the chairs of the Energy and Commerce, Ways and Means and Oversight and Accountability committees as well as the GOP Doctors Caucus.
The representatives said the scandal may "represent a significant failure by CMS and HHS OIG."
"This dramatic, multifold increase in catheter billing—from just a handful of companies—should have been quickly identified and addressed," the letter reads. "If public reports about the apparent ease with which this fraud was perpetrated are accurate, they raise questions about the efficacy of current CMS and the HHS OIG fraud detection and prevention measures."
Stakeholders familiar with the situation believe the fraud may total closer to $3 billion, and the perpetrator's strategy applies to diabetes supplies, according to a news release.
Diabetic supplies and skin grafting utilization has previously caught the eye of the National Association of ACOs. Health systems and states issued alerts as far back as August to be on the watch for potential fraud.
"It is imperative that HHS OIG take immediate action to reduce improper payments and ensure that taxpayer dollars are directed towards the care of our senior citizens whom Medicare is intended to serve," the letter said.
The committees are also concerned the agencies' unwillingness to discuss a potential ongoing investigation is hurting victims that must seek guidance through unofficial social medical channels.
They want to hear from the feds when they became suspicious of catheter billing fraud, what actions have been taken, the known financial impact and how fraud may occur with other healthcare items.
Republicans say they've prioritized fraud accountability, pointing to reduced Medicare improper payments from $41 billion to $28 billion per year by the end of President Donald Trump's term in office. In 2023, improper payments reached $31 billion per year.
A similar letter was sent by Republicans in 2016 to CMS, concerned that the agency was too focused on "outdated pay and chase activities."
But healthcare fraud has been a concern for Democrats as well. In 2022, House and Senate Dems urged the Biden administration to remove suspect organizations from the ACO REACH program. And, in the first summer following the COVID-19 pandemic, Democrats launched an inquiry into Medicare stimulus payouts, reported Reuters.