HJAR Sep/Oct 2019

HEALTHCARE JOURNAL OF ARKANSAS I  SEP / OCT 2019 35 be stemming fraud but isn’t.” She and her colleagues, she said, “want to know how CMS is using its authority to safeguard against health care scams like the one David Williams carried out for years.” And she noted that if the senators “find that the agency can be doing more, then we will look to arm CMS with the tools it needs to protect patients and taxpayers, or hold them accountable for the failure to use tools already at their disposal.” A spokesman for Medicare said that the agency would not have a comment on the senators’letter, but that it would be respond- ing to it. The agency has previously said that federal regulations don’t allow it to verify the licenses of NPI applicants. In their letter, the lawmakers said they would work with the regulators to identify any authority Medicare needs to address the security gaps. In an email sent to ProPublica after the Williams story was published, Medicare of- ficials quibbled with the story’s description of the NPI as “essentially the key that unlocks access to health care dollars.” A Medicare spokesman said that the phrase overstated the NPI’s significance because the identifier doesn’t guarantee payment or enrollment in a health plan or that the provider is licensed. But Medicare’s own literature says medical “One thing the nursing career offers that most other professions don’t offer is the wide variety of employment opportunities.” providers and plans “must use NPIs” in their financial transactions. Any claim submitted for payment is required to include a valid NPI. Medicare also asserted that providers must enroll with a health insurance plan to get paid. That’s true for Medicare, which covers people who are disabled or over age 65. But it’s often not the case with private insurers. TheWilliams story showed how “out-of-net- work”providers — those who are not part of a private insurer’s network — can still get paid. Joe Christensen, who spent five years as a director inAetna’s Special Investigations Unit and 13 years as director of Utah’s insurance fraud division, said health plans typically pay out-of-network claims without checking the providers’credentials. He said that makes the integrity of NPIs essential. “Anybody with an NPI can bill,”Christensen said. Others experts told ProPublica the same thing. Out-of-network billing is common with private insurance plans. A JAMA Internal Medicine study published this week showed about 42% of privately insured patients at in- network hospitals got out-of-network bills in 2016. If providers’licenses are not verified when they obtain an NPI, or when they sub- mit an out-of-network bill to a commercial insurer, it creates a massive opportunity for scammers. TheWilliams story also detailed the slug- gish response of insurers to clear evidence of fraud. The personal trainer’s ex-wife, Amy Lankford, and her father, Jim Pratte, discov- ered the fraud by happenstance and reported it to regulators and the insurers for years. Even after the insurers had ascertained that Williams was not a doctor, they continued to process his bills and pay him because he used new NPIs. In their letter, the senators also asked what Medicare could do to hold insurance compa- nies accountable for their response to fraud. On Tuesday, Pratte said the senators’ let- ter gave him hope. “It’s totally ridiculous,”he said. “Common sense would say you have to have some kind of credentials verified before an NPI can be issued.” Verifying NPI applicants’ credentials “would be a simple and significant step in addressing those issues,” Pratte said. The letter was signed by Cortez Masto; SheldonWhitehouse, of Rhode Island; Mag- gieWood Hassan, of NewHampshire; Tammy Duckworth, of Illinois.; Michael F. Bennet, of Colorado; and Robert Menendez, of New Jersey. The senators requested a response, in writing, by Sept. 9. n “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.”