Doggett Introduces New Legislation to Prevent Medicare Fraud

Contact: Doggett.press@mail.house.gov  

Washington, D.C. – U.S. Representative Lloyd Doggett (D-Austin), Ranking Member of the Ways and Means Health Subcommittee, introduced the Medicare Fraud Detection and Deterrence Act—legislation that would equip the Centers for Medicare & Medicaid Services (CMS) with the additional authority it needs to hold convicted Medicare fraudsters accountable and to stop repeat offenders. He also introduced the Preventing Medicare Telefraud Act—companion legislation to establish reasonable guardrails to prevent tens of billions of dollars in telehealth-related fraud concerning high-cost durable medical equipment and lab testing.

“Our health care system is plagued by a rising tide of health care fraud schemes—costing the Medicare program and American taxpayers tens of billions of dollars each year—and these are not victimless crimes. Medicare fraud and abuse risks the fiscal health of this vital lifeline for our seniors’ health care.” said Congressman Doggett. “While there is no single budget line item which can prevent and eliminate waste, fraud, and abuse, there are constructive steps we can take to protect taxpayers while preserving essential services. One concerns the National Provider Identifier number, which fraudsters may abuse to bill Medicare, and another addresses fraud in the rapidly expanding use of telehealth.”

The Medicare Fraud Detection and Deterrence Act would give CMS authority to deactivate a National Provider Identifier number (NPI) if the associated health care provider is convicted of waste, fraud, or abuse, and is added to the OIG Exclusions List.  It would also require CMS to implement important OIG anti-fraud recommendations that would improve NPI reporting and increase transparency about health care provider relationships with Medicare Advantage Organizations and telehealth companies.

An NPI is a unique, government-issued 10-digit number that is assigned to an individual provider or organization such as a durable medical equipment (DME) supplier or group practice. Providers are required to use their NPIs on claim forms in order to receive payment for Medicare services, and for other administrative and financial transactions covered by the Health Insurance Portability and Accountability Act (HIPAA). Incredibly, CMS cannot deactivate an NPI due to fraud unless a provider reports the fraudulent use of their own NPI. Providers who have abused our system are still permitted to use their NPIs to bill Medicare. 

The Preventing Medicare Telefraud Act would implement policy proposals from the nonpartisan Medicare Payment Advisory Commission (MedPAC) to establish reasonable guardrails on the ordering of high-cost equipment and services via telehealth. This legislation was included in the Telehealth Extension Act of 2021, prior legislation authored by Rep. Doggett which enjoyed broad bipartisan support. A version of the Telehealth Extension Act was included in the Consolidated Appropriations Act of 2023, though the anti-fraud provisions were excluded.

The Preventing Medicare Telefraud Act would require an in-person appointment at least six months prior to the ordering of high-cost durable medical equipment or lab testing. The Department of Justice has convicted hundreds of providers and telehealth companies for fraud pertaining to the ordering of these services and equipment—schemes that cost taxpayers tens of billions of dollars.

The legislation would also authorize CMS to audit outlier clinicians who order durable medical equipment or lab tests at high rates. These audits will expedite the recovery of any fraudulent payments of taxpayer dollars. Finally, the bill would require providers to use their own NPI when billing Medicare for a telehealth service to ensure greater transparency and data collection on which providers are ordering services and equipment. This provision is an extension of current policy for in-person services.

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