HJAR Sep/Oct 2019

34 SEP / OCT 2019  I  HEALTHCARE JOURNAL OF ARKANSAS The letter came in response to a recent story by ProPublica and Vox that traced the brazen scam of a Texas personal trainer, who despite having no medical credentials was able to submit a blizzard of fake bills with some of the biggest insurance companies in the country and recoup millions. The story revealed not only how David Williams ex- ploited weaknesses at each step, but how slowly the insurers responded to his ongo- ing fraud. Williams’con, for which he was later pros- ecuted, was initially enabled by the Centers for Medicare andMedicaid Services. The fed- eral agency issues and administers Nation- al Provider Identifiers, or NPIs, the unique numbers medical providers need to bill in- surance plans. ProPublica found that Medi- care doesn’t check the credentials of medical providers who apply for NPI numbers, such as whether they have valid licenses, which means scammers can lie to obtain them. Wil- liams obtained at least 20 NPI numbers and used them to bill insurers. The insurers he scammed — Aetna, Cig- na and UnitedHealthcare — then allowed his fraud to proceed for years, largely un- checked. The companies also failed to verify that Williams was a licensed physician, even as he billed them for complex, and expensive, office visits as an out-of-network provider. Instead, they paid himmore than $4 million over a span of four years, despite alerts from his ex-wife and her dad about his scam. Wil- liams was convicted of four counts of health In their letter, the senators asked the lead- ers of the Department of Health and Human Services and its Medicare division to detail what they’re doing to fix gaps in the system that allow fraud to flourish, including what measures Medicare has taken to strength- en the requirements for obtaining an NPI number. “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 wrote. In a separate email, Sen. Catherine Cor- tez Masto of Nevada, who spearheaded the response, said ProPublica’s reporting “high- lighted an area where the government could care fraud in 2018 and sentenced to about nine years in federal prison. The insurers de- clined to comment on his fraud. Current and former investigators for health insurers and federal prosecutors said the simplicity of Williams’ scam, combined with weak oversight and enforcement, raises questions about what’s being done to combat rampant health care fraud. Experts estimate fraud consumes about 10% of the country’s $3.5 trillion health care tab — although the story found that large swaths of fraud are not being tracked. Those losses are eventually passed on to the public in the form of higher monthly premiums and out-of-pocket costs as well as reduced benefits. Following a detailed account of how scam artists can easily gain access to health care cash, six Democratic senators this week sent a letter to federal regulators urging them to “close loopholes” that allow“bad actors” to commit fraud. Experts estimate fraud consumes about 10% of the country’s $3.5 trillion health care tab.