A U.S. lawmaker is taking action after a KHN investigation exposed weaknesses in the federal system meant to stop repeat Medicare and Medicaid fraud and abuse.<\/p>\n

Rep. Lloyd Doggett (D-Texas) said he decided to introduce a bill in the House<\/a> late last week after KHN\u2019s reporting revealed what he called a \u201cshocking loophole.\u201d<\/p>\n

\u201cThe ability of fraudsters to continue billing Medicare for services is outrageous,\u201d Doggett said. \u201cThis is an obvious correction that is needed to safeguard our system. Wherever there are large amounts of government money available, someone tries to steal it.\u201d<\/p>\n

KHN found a laundry list of weaknesses<\/a> that allows people accused or convicted of fraud to easily sidestep bans imposed by federal officials. Among those gaps is the Centers for Medicare & Medicaid Services\u2019 lack of authority to deny or revoke National Provider Identifier, or NPI, numbers after federal regulators have prohibited a person or business from receiving payments from government programs.<\/p>\n

Doctors, nurses, other practitioners, and health businesses use the unique, 10-digit NPI numbers to bill and file claims with insurers and others, including Medicare and Medicaid.<\/p>\n

Taking away the NPI would \u201cbe equivalent of prohibiting a practitioner from practicing in total,\u201d Dara Corrigan, director of CMS\u2019 Center for Program Integrity, wrote in an email response to questions about KHN\u2019s investigation. CMS declined to comment on Doggett\u2019s proposed legislation.<\/p>\n

The bill, HR 1745<\/a>, would give CMS the authority to deactivate NPIs tied to anyone convicted of waste, fraud, or abuse and whose name appears on the exclusions list<\/a> kept by the Office of Inspector General for the U.S. Department of Health and Human Services. The proposed law<\/a> would also require CMS to implement recommendations that the inspector general has made to improve NPI reporting and provider transparency.<\/p>\n

\u201cThis strikes me as what should be an easy bipartisan measure,\u201d Doggett said, adding that he had presented the bill in a face-to-face meeting with Rep. Jason Smith (R-Mo.),<\/a> who chairs the House Ways and Means Committee. Doggett also alerted that panel\u2019s health subcommittee chair, Rep. Vern Buchanan (R-Fla.).<\/p>\n

\u201cThey both talk about the need to eliminate fraud, and this is one modest but important way to do it,\u201d Doggett said. Neither Smith\u2019s nor Buchanan\u2019s offices responded to requests for comment.<\/p>\n

The OIG declined to comment.<\/p>\n

Former Justice Department officials told KHN that repeat violators are savvy and find ways to circumvent the system. KHN examined a sample of 300 health care business owners and executives who are among more than 1,600 on the OIG\u2019s exclusion list since January 2017. Journalists reviewed court and property records, social media, and other publicly available documents.<\/p>\n

KHN found:<\/p>\n

Eight people appeared to be serving or served in roles that could violate their bans.<\/li>\n

Six transferred control of a business to family or household members.<\/li>\n

Nine had previous, unrelated felony or fraud convictions, and went on to defraud the health care system.<\/li>\n

And seven were repeat violators, some of whom raked in tens of millions of federal health care dollars before getting caught by officials after a prior exclusion.<\/li>\n<\/ul>\n
Doggett\u2019s bill is \u201ca pretty smart step in the right direction in fixing this issue,\u201d said John Kelly, a former assistant chief of health care fraud at the Department of Justice who is now a partner for the law firm Barnes & Thornburg. Kelly had previously recommended that NPIs should be \u201cessentially wiped clean\u201d when a person is on the exclusions list.<\/p>\n
Kelly, who confirmed that Doggett\u2019s office reached out to him after KHN\u2019s investigation was published in December, said taking the NPI number away \u201ccertainly doesn\u2019t eliminate all risk\u201d but it\u2019s a move \u201cin the right direction.\u201d<\/p>\n
\u201cIf you want to bill Medicare, you have to have a valid NPI,\u201d Kelly said.<\/p>\n
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