Medicare Fraud: Policy Resources, Roles, and Realities

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The thing that the Alliance brings is bipartisan trust. And you can see it here in this survey. And you can also see it through, you know, throughout our programming. So we

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When we think about how we built that foundation of trust, there’s really three different ways. One is we have an incredible history. So for those of you who are new to the Alliance, you should know it’s a 35-year-old organization with a great history. We have made a landmark investment in the last two years, really to reinvigorate our commitment and our mission to educating the policymaker community

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around complex topics in health policy. And then we have a very specific and deliberate approach to our policy to really protect the trust that we’ve earned. So I’m going to talk for a minute about each of those things.

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Starting with our history. So 35 years ago, Senators Rockefeller and Danforth wanted a nonpartisan, trustworthy source of information on healthcare policy because it was very complex and they thought it was getting increasingly partisan. Imagine that

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What we have found over the 30 plus years is that we haven’t just built great content and had great experts, but really have built a community of learners, people who have benefited from the alliances program over the years have gone on to have incredible careers in healthcare policy

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and become the experts themselves. So that is that is part of the legacy of this organization, and it has, as I mentioned, been reinvigorated as we think about our second pillar there in terms of our trust, which is the congressional fellowship. So when we think about the last two years, we have spent

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About 10 months each year with 30 early career congressional fellows who have raised hand and said they are interested in being health policy leaders. So that’s a 50-50 bipartisan split, true to that vision set out by Senators Rockefeller and Danforth

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And

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We have spent our time not just helping them build their knowledge, but also their skills and their networks so that they can advance in their careers. So when you invest in folks, I think that is a key to helping build a unique amount of trust

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Finally, we think about our incubate to educate approach to our programming, which is very relevant for what we’re going to talk about today. We don’t just show up with sort of an idea and some funding and go right into educational work. Instead

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We do really deliberate listening, which takes the form of, you know, in-depth interviews. It takes the form of workshops where we talk to folks drawn from that incredible community we’ve built over 30 years. And we turn it into recommendations for what our educational curriculum could be. So what that means is when

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You see our educational work, you know that it has been thought about across different stakeholders, across the aisle, and that multiple perspectives are included in how we shaped and created the educational work we’re doing. So that includes today’s webinar. It also includes

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The five questions tool that we co-developed with the experts that we had in our workshops

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really focused on determining and discerning when we look at fraud, waste, and abuse, what might be fraud, what might be waste and what might be abuse, and what might be something else. So that was a high priority identified by the group, and that was the sort of educational resource that we created together. So

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With that in mind, you can see that today’s program is no exception. We just completed our Fraud Waste and Abuse Seminar, and these materials are available for you all that are products of that incredible listening and community

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time we spent together. So I have a couple things I want to share with you before we jump into the webinar itself. And the first one is that we want to hear from you. Listening is something we do, not just say, and there’s a Q&A function at the bottom of your screen. We want to encourage you to share questions

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You know, when sort of the question spirit hits, go ahead and share a question. You do not need to wait to the end, so make sure you’re taking advantage of that. Speaking of questions, I’m going to start with a question. We’d love to listen to you all. And so we are leveraging the Zoom poll

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To hear from folks, you know, how confident do you feel that you understand fraud, waste, and abuse in healthcare? There’s no wrong answers here, but we just like to kind of level set with folks before we dive in.

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So great, I’m seeing wow, great number of respondents. Thanks everybody for participating. What we’re seeing is somewhat confident. I think that’s exactly why we want to start here. There’s always more to learn. We’ve got some very confident folks. Hopefully they’ll take away one or two insights

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And if you’re not very confident, hopefully this is going to give you some great resources and some great preliminary questions so that you can figure out where you want to dig in next.

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With that, I think we’ll go to our next

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Slide, fantastic. And I want to just take a moment and say thank you to our sponsor. So as I mentioned, you know, one of the great things about working at the Alliance for the Health Policy is that we don’t have like a lot of opposition. We’ve got a lot of people

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Who really share our mission and think that what we do is important, and we’re so grateful for that community. But I think it’s important to note that someone like AARP has gone beyond that and really invested in education for our policymaker community and for everyone who’s able to join the Zoom

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And everyone who’s able to download the webinar later. So we are very grateful for their investment in our programming so that we can bring these incredible experts that you’re going to hear from next to you to help you think, you know, more deeply and to understand better

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What’s going on in the world of Medicare fraud. So

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If we go to the next slide, you can see I’ve got one more listening opportunity here. We’d love to hear, you know, when you see a headline about improper payments in Medicare, what really comes to mind? What do you think they mostly involve? So

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We see kind of… I’ll give you a second there to… for everybody to think about it and give us your thoughts.

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Interesting. So we’re seeing a mix here, which I think our experts would agree there is definitely a mix when it comes to what kind of falls in these buckets, fraud and waste and abuse and other or different categories. And so these things can all fall into two different ones of those categories

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And, you know, that’s something, you know, you might hear a little bit more of about in today’s webinar. So thank you all so much for sharing your thoughts, and we are eager to get into our conversation today.

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It’s, I am thrilled to introduce Leslie Gordon, who is the director at the USGAO. She leads GAO’s oversight of the Medicare program, including its efforts to prevent fraud

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Leslie’s career, we like at the Alliance, we always like to highlight what’s kind of unique about someone’s career. And I would say when I was reviewing Leslie’s bio, what struck me is that, you know, Leslie has really taken the approach of really understanding programs in depth, particularly the Medicare program

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And she’s built and applied the skills of analysis and oversight over time. So since she joined GAO in 2000, she spent more than 25 years examining how the program works, including traditional Medicare and Medicare Advantage, recommending more ways to make it more efficient and effective

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And that depth has made a measurable difference. So her work on Medicare payments has helped prompt agency and congressional actions that resulted in billions of dollars of federal savings. Most recently, she’s led the GAO work on data analytics for fraud prevention, hospice payments, Medicare Advantage, and payment models.

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We, you know, she holds a master’s degree in public policy as well as her bachelor’s from University of Notre Dame, and I think she’s exactly the right person with that broad lens and that depth on Medicare to lead our conversation today. So

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Thanks so much. I’ll turn it over to Leslie

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Thank you, Claire. It’s a privilege to be here. I’m really pleased to open this panel and moderate it. It is also a privilege to lead GAO’s work on the Medicare program. As you know, GAO

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is aimed at supporting Congress with objective, nonpartisan, fact-based information to improve federal programs and taxpayer dollars. And GAO has been looking at program integrity in Medicare for several decades before my time, last night when I was preparing, I looked back to see how far I could go and I saw a report from 1978 that noted problems

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in the allowability of reimbursement for certain home health care costs. 1978. And we have ongoing work looking at Medicare fraud issues. JAO also highlights programs that have the highest risk

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For the federal government. And Medicare was a founding member in 1990.

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These are programs with serious vulnerabilities or effects on the federal budget. And I’m so pleased that the Alliance has chosen to start its examination and webinar with an examination of fraud in the Medicare program

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Because Medicare is susceptible to fraud, waste, and abuse due to its size and its complexity

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It’s where the money is

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It’s $1.2 trillion dollars for services for 70 million Americans in 2025. CMS processes a billion claims a year

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So, 1.5 million providers and clinicians through 20 different payment systems

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And almost all Americans have a stake in the financial condition of the Medicare program because its impact on the federal budget

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You know, like GAO, this alliance panel is about providing nonpartisan information

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Today, we’re going to talk about how the system works, not how it should work

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But we’re going to ask our panelists, and they’re not going to take policy positions or make recommendations. This is an all-star panel that has touched the Medicare program for decades and worked to advance program integrity and really understand and make sure the program works

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So we’re not going to be assigning a credit or blame to anyone for operating it. We’re here to talk about the machinery

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The Alliance has assembled an exceptional panel, and we’re going to go beyond identifying the problem. We’re going to get to… hope to get to a better understanding of what can be done

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Who can do it, and which tools are readily available. With that, I’d like to introduce our esteemed panel

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You can have

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I would like to start with the esteemed panel. First off, Kimberly Brandt is CMS’s Deputy Administrator and Chief Operating Officer. Previously, she held responsibilities in the private sector where she provided strategic advice on a broad array of healthcare regulatory enforcement and policy manners

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at Tarplin Downs & Young. Kim has held multiple senior executive positions in the government, including serving as principal Deputy Administrator for policy and operations during the first Trump administration. In that role, she oversaw activities

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necessary for the operation and management of CMS’s $1.4 trillion budget, in addition to leading efforts to reform physician self-referral regulations and develop the first CMS interoperability rule.

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Kim previously served as Chief Oversight Counsel and general counsel on the staff for the US Finance Committee, where she led multiple investigations and she has had previous experience in government serving as a CMS director in the Medicare Program Integrity

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Working at the HHS Office of Inspector General as senior counsel.

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We are also joined by Dr. Bartley Bright. He’s Chief Medical Officer for Privia Health, a technology-driven national physician enablement company. Privia Health delivers tools, talent, and technology which enable clinicians in their care centers to support

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The practice of medicine, both in fee-for-service and value-based care arrange contracts.

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The ZVA Health is pursuing the quadruple aim to reduce unnecessary costs, achieve better health, and improve the patient and provider and staff experience.

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Privia has a presence in 25 states and DC, with over 1,300 practices, more than 6,000 clinicians that care for over 6 million patients, including 1.2 who are in value-based care arrangements.

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Dr. Bright began his career at Kaiser Permanente after training and residency at NYU in New York.

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We are also joined by Lisa Ray. Lisa is a nationwide authority on healthcare fraud enforcement and compliance who joined Arnold Palmer as a partner last fall

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After her 20-year career at HHS Office of Inspector General as Assistant Inspector General for Legal Affairs and acting chief counsel, she served as HHS representative for the False Claims Act cases

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boarding closely with the Department of Justice.

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She led OIG’s administrative litigation and exclusion program, established enforcement priorities, and oversaw its self-disclosure protocol, as well as corporate integrity agreement enforcement.

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Louis Focochio has served as the CEO of the National Healthcare Anti-Fraud Association.

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It was established in 1985 as a private-public partnership. The NHCAA is a leading national organization focused exclusively on combating healthcare fraud and abuse.

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Its members comprise more than 90 of the nation’s most prominent healthcare insurers, joined together with more than 225 federal, state, and local law enforcement and regulatory agencies.

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Lou began his service as the Chief Staff Executor at NHCCA in 2005. His background includes legal, operational and business management experience

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Prior to his service on NHCAA, he served as general counsel and Senior Vice President of Professional Services at America’s Health Insurance Plans

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We are also joined by Lindsey Copeland. Lindsay Copeland joined the Medicare Rights Center as Director of Federal Policy in 2017, based in Washington, D.C. She’s responsible for formulating, directing, and implementing Medicare rights beneficiary-centered federal policy and advocacy agenda

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Prior to joining Medicare rights, she oversaw federal advocacy and government affairs for several national nonprofits that focus on health and aging policy. As you can see, the Alliance has put together a diverse panel with

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very important perspective and a depth of expertise and experience in addressing Medicare’s program integrity work.

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I hope you enjoy.

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Over to you, Kim.

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I would say, sorry, I thought that was my cue, but I wasn’t quite sure. All right, if you could bring up my slides, please, that would be great. Good afternoon, everyone. So happy to be here, and especially to be with so many great people on this panel, all of whom I’ve had the pleasure of working with in various capacities

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Today I wanted to give you a brief overview of what CMS is doing to address fraud, waste, and abuse, in our programs. To that end, I put a short video, which you can watch or not watch at your leisure, in the chat. Dr. Oz, our administrator, and I

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have been trying to spread the word about a lot of the work that we’ve been doing. We have a short documentary that we recently released, which is what I put in the chat, so if you’re interested, please feel free to take a look at it when you need to be put to sleep, or if you need something else to do, but it’s a good sort of overview

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of a lot of the work we’ve been doing. So with that, if you can go to the next slide, please.

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At CMS, we’re guided by many things, but our number one mission is to make sure that our most vulnerable people that we serve, all 160 million of them, receive high-value care. Program integrity is critical to that mission, because every dollar that we lose to fraud, waste, and abuse

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is a dollar that’s not available for care for those 160 million Americans that rely on us through Medicare, Medicaid in the marketplace. So the strategic objectives that you see on this chart are all connected. Prevention, affordability, stronger payer function, and fraud reduction

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reinforce each other. And when CMS protects the integrity of the programs, our goal is to hopefully also be protecting the beneficiaries, the providers who play by the rules, and taxpayers. And this is really critical, and we take this very importantly because the first pillar of that is for us to be a leading payer

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And we are, we’re the world’s largest health insurer. When Leslie was giving my bio, I was thinking, wow, things have changed quickly. It used to be a $1.4 trillion budget when I was here my second of 3 tours at CMS. And as of today, we just briefed Dr. Oz on the new operating plan, and our budget is now 2.5 trillion, which is a huge increase in just a relatively short period of time, but largely because of the fact that more beneficiaries come onto our roles every day.

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Every day, 10,000 new seniors age onto Medicare, which is a huge responsibility for us to provide care for them, but it also means that we need to ensure the programs last so they can get those benefits that they’re signing on to. So if you can go to the next slide

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Let me talk a little bit about how it is that we have done our program integrity work here at CMS. Historically, since I started here during Tour 1 back in 2005, program integrity had meant you pay the claims first and then you attempt to recover the funds later

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That is what I spent a lot of my adult life trying to fight against. That approach has a lot of limits. Once money leaves the program, recovery can be slow, partial, or impossible. We only get about 10% of what goes out the door back

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And we’re lucky if we get that. So what we’ve tried to do is sort of shift the paradigm here over the last couple of years. And now we’re emphasizing prevention, which means that we’ve had to completely rethink how we’re doing our fraud, waste, and use approach. And we have put in place strong front end screening

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More real-time analytics taken much more aggressive prepayment actions. We’ve done more targeted claim edits. We’ve been focused on enhanced enrollment controls to make sure we know who we’re doing business with and whether they’re good partners to us. And we’ve been collaborating a lot more with law enforcement and the state partners

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You’ll probably hear more about that when Louis speaks, but in general, one of the things I think has been most marked over the last couple of years is we are now in it to win it with our partners. We work very closely together

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Not a day goes by that I’m not talking to the Department of Treasury or the Department of Justice, and we speak with the Office of Inspector General all the time, and those are our partners to help us make sure that we’re not only doing good prevention, but we’re very coordinated on the recoveries as well

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But the whole goal here is to stop improper payments before they occur and not just simply document them afterwards.

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So if you go to the next slide

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These are some of the strategies that we’re using to try and do this. It’s multi-layered, as you can see. Education and outreach is a big part of this because it helps beneficiaries and families recognize and report suspicious activity. A good example of this is you may have heard about some of the work we’ve been doing with respect to fraudulent hospices in California

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We have literally hundreds, if not thousands now, of beneficiaries who have been enrolled in hospice programs without their consent or their knowledge, or because they thought they were enrolling for something else. But bottom line is they got enrolled in hospice and they didn’t fully understand what that meant

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So now we’re sending letters to those beneficiaries saying, did you know that you were enrolled in hospice, or did you know that your loved one was enrolled in hospice? Did you agree to that? It’s really important because once a person enrolls in hospice, that means that they’re giving up the rest of their Medicare benefits

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That means they’re no longer entitled to preventative care or care that is going to help them recover. It’s supposed to be more palliative care. That’s a huge difference, and people need to understand that. So educating people that these types of scams are existing and that they need to watch their explanation of benefits

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To see when they’re billed for something that seems improper and to make sure that they know whether or not they’re getting enrolled in something they didn’t agree to is really, really important. We also have been using new tools, the new superintelligence, artificial intelligence, and machine learning tools

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are huge, because that’s helped us bring data analytics and specialized teams to bear on high-risk billing patterns. Just this week, actually, we had an incident on Monday where, thanks to some of the front end screening we’re doing in our Medicare war room, we were able to identify a durable medical equipment supplier

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who was doing $24 million of claims that were being submitted in one day.

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One day $24 million. Ultimately, we were not only able to stop that, but stop a total of $86 million from going out the door for that particular supplier. We never would have been able to do that even two years ago, let alone 15 years ago. But now we have the ability to be able to see those kind of billing patterns in real time

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And stop it before any of that money goes out the door, which is huge. As I mentioned, the collaborative action is really important as well. We work with our law enforcement partners, states, and other partners like Social Security, Treasury, and the Veterans Administration

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So that we can make sure all of our actions, the referrals, the investigations, the prosecutions, and our administrative actions, all reinforce one another. A great example of this is we’ve recently been delegated with the HHS OIG and Exclusion Authority. The HHS OIG does a great job on the exclusions and is definitely still the lead on those

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But this gives CMS the chance on the permissive exclusion side of the house to be able to take action more quickly on some of the people that we see that we are revoking from the Medicare program and are now able to exclude them so they can no longer bill the Medicaid, VA or TRICARE programs as well.

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Which is a huge benefit and a significant tool in our toolbox

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And then lastly, we’ve been using a lot of our more robust oversight tools. We’ve been doing moratoriums, which are 6 month periods of time where we stop enrolling new providers and suppliers in a particular area. We’ve done threes thus far this year. The first was for durable medical equipment, which went from

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In February until August, when we decided to lift the moratorium so that people can enter the program to participate in our new competitive bidding program. And then we have two ongoing moratoriums where we’re not letting people enroll in hospice or home health because we think that we have enough people in them right at the moment, and we want to make sure that we’re cleaning up the people who are participating before we let any new people in.

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What’s really significant about that is that just yesterday we were in California and we were able to take a look at several home health and hospice providers in Los Angeles, and we were able to identify 56 home health agencies that didn’t even meet the scratch test for continuing to look like they were viable entities or provide care.

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We were immediately able to revoke all of those, and 36 of them were in the same building. So what our goal here is, is to kick the people out who are legitimately, or who are actually not providing the services and make sure that we’re focusing then on keeping in the people who are legitimately providing the services so that we can protect the programs

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And then if you go to the next slide

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We’ll end up with some of the more recent actions that we’ve taken. I’ve alluded to a couple of them, but I want to go a little deeper on the moratorium. As I announced, we’ve done the moratoriums for home health, hospice, and durable medical equipment. But for the first time ever in September, we actually announced a temporary moratorium

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On new registration for agents and brokers. This was really significant because of the fact that this is the first time that we’ve held agents and brokers to this level of accountability. What’s also significant is since January of this year

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We have issued termination notices for over 200 noncompliant agents and brokers. And what we have done is that any agent and broker that doesn’t have an active exchange agreement is now going to be part of this moratorium.

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The National DME Enrollment Moratorium that I alluded to before was significant because during that six month period of time, we were able to take action over a thousand durable medical equipment suppliers who were already participating in the CMS programs and able to kick them out of the program

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Meaning that we stopped 1.56 billion from being paid out as a result of that, a huge dent in the DME fraud that we’ve had here at the agency and hopefully being able to make it so now we can keep those people out thanks to some of our new authorities

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And then lastly, as I’ve talked about, the home health and hospice moratorium is still ongoing and will be announcing a decision as to whether we’re going to continue that or not in the next couple of weeks. But we have been able to take more than 1,000 hospices, a 47% reduction

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Out of the Medicare program just over the last year and a half. This is significant because we’ve not been hearing from people that they can’t access hospice services. But what we have been hearing is that the billings for hospice have gone down as a result of this.

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So again, this is kind of a quick high-level overview, but I encourage you to go if you want to, if you go to the next slide, my email address is on there. Feel free to email me and also go to cms.gov/fraud for all of the stats that I just talked about and more information. And if you have time, take a look at the video and learn a little bit more.

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And with that, I’ll hand it back to you, Leslie.

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And we have Dr. Bright next.

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Great. Thank you for, let’s see.

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Am I unmuted?

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Great. Thank you for

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Inviting me to the panel and Kim, for your comments and for the work that you do as a risk-bearing medical group

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It’s really, really important that the payer not not doesn’t pay and pursue but stops when you know something confidently that you should stop. So hats off to you for that. Thanks so much.

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Privia, I’m going to introduce. I’ve got a couple of slides I’m going to go through, just introduce who Privy is. You can sort of understand how we think about the healthcare ecosystem, especially in relation to fraud, waste, and abuse

00:28:53.000 –> 00:29:04.000
Then a couple of real life case examples from the past year or two, similar to the way that Kim did. And then finally, what we do as sort of a structure and process all year long to try and

00:29:04.000 –> 00:29:24.000
Monitor for it within our own groups but also in the healthcare spend that we are responsible for. And so Privia’s mission is basically quadruple aim, as Leslie said at the beginning. We want to empower physicians. We really are, we work with independent physicians who are owning their practices

00:29:24.000 –> 00:29:29.000
We want to enhance the patient experience and their health, and most definitely keep

00:29:29.000 –> 00:29:43.000
Physicians and nurse practitioners, PAs engaged in the healthcare system because we believe that the when the physician or the clinician is owning a practice, they’re providing better care to the patient as opposed to being an employee of somebody else.

00:29:43.000 –> 00:29:56.000
The slide that you have before you is one view of what privy is. So we are independent, community-based, single tin integrated EMR delivery systems. We have medical groups that

00:29:56.000 –> 00:30:14.000
In their various dates, they’re geographically co-located, they’re not spread out where they’re not, sort of, in these common delivery system areas or common payer areas. Each one of the Privia Medical Group members, that really means a clinician, mostly physicians, they own their care center. They employ their staff, they buy their own tables and chairs

00:30:14.000 –> 00:30:30.000
If they don’t work, they don’t make money. If they do work, they do make money, both in fee-for-service and the VBC side. That’s very important from our point of view for this aligning of incentives between what Privia does, which is not the medical group, and what the medical group and importantly, the care centers do

00:30:30.000 –> 00:30:32.000
Who within the medical group

00:30:32.000 –> 00:30:44.000
We’re predominantly primary care, as you can see on the slide. We do have medical specialists, not so much interventionalists and some surgical specialties. So we definitely have specialists.

00:30:44.000 –> 00:30:58.000
As Leslie mentioned, we’re across a bunch of states, 6,000 clinicians, a lot of locations. The patients you can see. Importantly, for fraud, waste, and abuse, or it’s all important, but important for the physician

00:30:58.000 –> 00:31:02.000
practice survival for Privia Health to thrive

00:31:02.000 –> 00:31:18.000
When we are taking risk from both the federal government and from a private payer, and I’ll define risk in a second, across a million and a half patients, it’s important that we are paying for healthcare, that our payers are paying for healthcare, because we don’t take claims, unlike some

00:31:18.000 –> 00:31:30.000
California medical groups, which I won’t go into. It’s just important that that money is spent reasonably. If you think about how healthcare spend happens, about, you know, most patients see a primary care clinician

00:31:30.000 –> 00:31:49.000
But most spend, most healthcare expense happens outside of the primary care office. So the primary care physician is thought of as the quarterback. But then there’s the specialist, then there are the facilities, then there are the hospitals, and there’s just a tremendous amount of expense that happens outside of the primary care office, DME, hospice was mentioned a lot in Kim’s conversation

00:31:49.000 –> 00:31:57.000
And our ability to manage that, the further away it gets from us, especially in a PPO world where the patients can do as they

00:31:57.000 –> 00:32:07.000
Please, in terms of accessing care, it’s just harder and harder to control. So fraud, waste, and abuse is one of those threats to our properly managing expense while we demonstrate that we have quality.

00:32:07.000 –> 00:32:21.000
And so our physicians are dedicated partners with us. Privia Health is an administrative partner and we do all of the contracting fee-for-service value-based care for all contracting types, Medicaid, Medicare, ACCA

00:32:21.000 –> 00:32:23.000
commercial, etc.

00:32:23.000 –> 00:32:40.000
We run the EHR, we run rev cycle, we do credentialing, we do training, etc. We do not employ the physicians or run the care centers. At some point, we might, but right now we don’t. And importantly, we do analytics and reporting. And in analytics reporting is where a lot of fraud, waste, and abuse detection

00:32:40.000 –> 00:32:44.000
begins. So next slide, if you would, please

00:32:44.000 –> 00:32:46.000
So I’m going to walk through two case studies

00:32:46.000 –> 00:32:53.000
In this case study, this all occurred about a year and a half ago, and many on the phone, I’m sure, are aware of it

00:32:53.000 –> 00:33:00.000
We identified a tremendous spike in one single HCPCS code, A6197, small bandage

00:33:00.000 –> 00:33:16.000
And it was such a large spike that you almost had to be blind not to see it, but we noticed it. But then we had to decide, well, what are we going to do about that? Because just because there’s some spike in healthcare expense doesn’t mean it’s fraud, waste and abuse. As many know, healthcare is expensive

00:33:16.000 –> 00:33:25.000
Many chemotherapy drugs or cancer treating drugs, I should say, are now hundreds of thousands of dollars per treatment. So expense happens very, very, very quickly.

00:33:25.000 –> 00:33:39.000
What we noticed was that for dates of service in 2024, we were getting this tremendous bolus of claims. Now, we’re not paying the claims. The claims come in in this case, to CMS. CMS through their administrators, pays those claims. We noticed this tremendous, or I should say

00:33:39.000 –> 00:33:57.000
adjudicates the claim, whether or not these got paid, Kim could comment on, but may not. So those claims look in our reports that come from CMS, like we had this tremendous, tremendous expense, literally multiple, you know, large percentage of our overall spend. We then identified additional codes that were sort of

00:33:57.000 –> 00:34:08.000
really anomalous in their volume, both patient-wise and in claim counts. And at the bottom, you can see there that the claim counts increased by 38-fold. That’s 3,800%.

00:34:08.000 –> 00:34:16.000
And the cost per claim increased by 7.5x, that’s 7,500%. And what was interesting was that all these patients

00:34:16.000 –> 00:34:24.000
had roughly the same claim going out the door. Multiple units of a relatively inexpensive bandage

00:34:24.000 –> 00:34:26.000
And so we thought, okay, this is the problem.

00:34:26.000 –> 00:34:35.000
So we analyze the data now on the middle column of investigation, we get the file from CMS on a regular basis that is claims.

00:34:35.000 –> 00:34:41.000
It showed a range of ordering clinicians. Some of the clinicians were clinicians in our own practice

00:34:41.000 –> 00:34:51.000
And so you thought like, oh, that doesn’t feel so good. So we audited our own practices. None of those practices had ordered these claims. None of the patients that we audited

00:34:51.000 –> 00:35:03.000
Had a medical necessity, that’s a clinical assessment of the patient. Did they need the type of bandages that were being spent being administered or provided to the patient on a regular basis at these very large numbers

00:35:03.000 –> 00:35:06.000
And so we concluded something

00:35:06.000 –> 00:35:18.000
Is amiss here because patients don’t need it, we’re not prescribing it again, it’s getting prescribed and on the claim we’re listed as the ordering provider, which of course worries the clinicians, license threats, medical boards, etc.

00:35:18.000 –> 00:35:35.000
We did interviews with our clinicians. And then we had to think, okay, what’s next? Because we don’t pay the claims. We’re not doing the order. Like, how do we control this? How do we stop it, much less get back? So first place you go is to the government agencies. We reported

00:35:35.000 –> 00:35:46.000
appropriate ones, OIGCMS, etc. We also made a broad communication to not just our physicians, but to the MAs and office managers in our practice. This is happening.

00:35:46.000 –> 00:35:53.000
Be aware of it. Now, since they’re not ordering it, what’s there to be aware of? But let’s just raise the awareness

00:35:53.000 –> 00:36:00.000
We then took an approach by finding others out in the states who are identifying similar trends

00:36:00.000 –> 00:36:03.000
ally with them, and then

00:36:03.000 –> 00:36:21.000
pursue, advocate to the payer, in this case, the federal government, to one protect us from the risk that we believe we now are bearing financially, which we thought was really not fair, but also can we just stop the bleeding? Can we stop the payment

00:36:21.000 –> 00:36:24.000
It took some time, but in the end

00:36:24.000 –> 00:36:29.000
CMS was doing other internal investigations, which I’ll not go through

00:36:29.000 –> 00:36:45.000
And this set of codes for the second time in two years was identified as likely significant and anomalous, and the claims were being stopped. Some of the entities, I imagine, are still being pursued, and we felt that

00:36:45.000 –> 00:36:51.000
At least at that moment, that some protection had happened. Next slide, if you would.

00:36:51.000 –> 00:36:57.000
So if we’ve gone out and we’ve told our clinicians and our office managers and our MAs that kind of thing is happening.

00:36:57.000 –> 00:37:12.000
Well, now we’ve got awareness in more than 1,000 care centers across a bunch of states. And this is, we want our patients to understand too, because the patients, as I think Kim mentioned in the hospice scenario she described

00:37:12.000 –> 00:37:26.000
They get their EOBs, their explanations of benefits, and when they see something that doesn’t make sense, they need to come in and tell us what’s going on, so maybe we can do something. They also need to individually report, but that doesn’t happen nearly as often as probably it could. So in case study 2

00:37:26.000 –> 00:37:34.000
A patient comes in and says, you know, I got an EOB, it says I got this service, you know, I didn’t need this service.

00:37:34.000 –> 00:37:49.000
We investigated in a similar process, middle column here. It turned out that indeed the patient did need a service, they got it, they didn’t simply understand it, but there was no big tail or big expansion of this fraud. But we have to take each one of these

00:37:49.000 –> 00:37:57.000
observations, each one of these reports seriously, or we tend to miss it. Next slide, the interest of time.

00:37:57.000 –> 00:38:03.000
So what do we do? We have to prevent it. We’ve got to detect it, and then we’ve got to remediate it.

00:38:03.000 –> 00:38:11.000
And so data security is extremely important. We talked at the beginning about compliance.

00:38:11.000 –> 00:38:25.000
You know, we have a lot of data from all of the patient care that we provide, all the billing data, etc. And we’ve got to behave securely with it while we have to transact with our various healthcare partners on all of these data elements.

00:38:25.000 –> 00:38:34.000
We believe, but we don’t have proof of it, that, you know, somehow our physician names and their NPIs made it into the first case example. So

00:38:34.000 –> 00:38:49.000
We continually work on our data security, and it gets harder and harder in the AI era, which I won’t go into. We train all of our clinicians and all of our billers about billing and coding so that they are not

00:38:49.000 –> 00:39:04.000
Doing so they are properly identify coding for supporting the care that they provide. So because again, there’s fraud, waste and abuse, fraud being you didn’t do something wasteful, probably wasn’t necessary. Abuse was you knew it wasn’t necessary, but you did it anyway

00:39:04.000 –> 00:39:19.000
But very high level description. We then do annual compliance training, even though we don’t own the care center. Every single employee and every single physician has to do our compliance training, which we update with whatever the current information is. And

00:39:19.000 –> 00:39:21.000
For interest, we’re in

00:39:21.000 –> 00:39:34.000
Shared savings programs, financial risk. If you don’t complete your compliance training, then you’re not eligible to share any of the savings that we generally do save for CMS over the past five, ten years.

00:39:34.000 –> 00:39:49.000
And then there’s education point of care awareness, which I mentioned before, and then importantly, who do we refer patients to? Now, we don’t have total control because patients can go where they please, certainly in the traditional Medicare market, but knowing who referring patients to is very important

00:39:49.000 –> 00:40:03.000
to deterring abnormal behavior on the path of clinicians. I’ve talked a bit about analytics and reporting, this detection front. We monitor public reporting. Kim went through a bunch of things of providers being suspended

00:40:03.000 –> 00:40:25.000
or activities that are being noticed, we look at the OIG action plan to make sure we’re paying attention to that. We invite case reporting to our compliance lines, as I described in case number 2. We’ve got a compliance department, you know, as an entity, as a position group, we’re pretty large. We have pretty good resources. Imagine a small practice who isn’t part of an entity that has administrative capabilities like we do

00:40:25.000 –> 00:40:42.000
To do all of these things exceptionally, exceptionally hard, especially with the, I love the one word, the 33 entity that one location is really just incredible. But how do you figure that out if you’re a solo practice?

00:40:42.000 –> 00:40:55.000
Clinicians rely on that for CMS to do that, for the MA payers to do it, for the commercial payers to do it. Oh, we then have an internal audit department where we’re auditing every clinician, every practice all year long.

00:40:55.000 –> 00:41:10.000
And remediation is really the bullet you see there on the right. Understand the exposure, develop prevention tactics, collaborate with those around the country who have similar interests and similar capabilities, because maybe together we can develop better rules for

00:41:10.000 –> 00:41:21.000
investigation to detect fraud, waste, and abuse. And then, of course, agency reporting, and then stopping referring patients to clinicians that we don’t trust.

00:41:21.000 –> 00:41:26.000
So I’ll stop there, back to you, Leslie, or wherever.

00:41:26.000 –> 00:41:31.000
Lisa’s up and my apologies, Dr. Britt.

00:41:31.000 –> 00:41:34.000
Why?

00:41:34.000 –> 00:41:37.000
I was calling you, Dr. Bright. You are bright.

00:41:37.000 –> 00:41:42.000
But you’re also Dr. Britt. Lisa, over to you.

00:41:42.000 –> 00:41:57.000
Good afternoon, everybody. First, I want to say a very special thank you to the Alliance for inviting me to be with you this afternoon. It’s truly a privilege to talk about something that I really love, actually. I spent

00:41:57.000 –> 00:42:07.000
As I mentioned, I spent 20 years at HHS-OIG, and so my professional career really was founded in healthcare fraud, enforcement and compliance

00:42:07.000 –> 00:42:22.000
For the next 10 minutes, I really want to walk through what government enforcement, how healthcare fraud cases, how they evolve, who are the enforcers, how the cases are identified, how they get charged, and how they end

00:42:22.000 –> 00:42:37.000
I’m not going to cover every detail that’s in this slide deck. The point of the heavy slides was for you to have references to the concepts that I’m talking about, so that you can have it after the conference is, or after this presentation is over. Next slide

00:42:37.000 –> 00:42:38.000
Please

00:42:38.000 –> 00:42:47.000
So let’s start with the nuts and bolts of enforcement. There are three primary health care fraud enforcement tracks

00:42:47.000 –> 00:42:50.000
Civil, criminal, and administrative.

00:42:50.000 –> 00:43:07.000
DOJ drives the criminal and the civil enforcement, and OIG and CMS drive the administrative enforcement. I’m going to walk through the key laws on another slide. What I want to focus on here is how the agencies are working together

00:43:07.000 –> 00:43:10.000
So who does what when

00:43:10.000 –> 00:43:25.000
On the enforcement side, the agencies work hand-in-glove together to coordinate behind-the-scenes in investigations. Sometimes investigations are ongoing for several years, and the entity, the target, may have no idea that the investigation even exists.

00:43:25.000 –> 00:43:36.000
OIG and DOJ investigate the allegations, however they were identified. Subpoenas are issued, requests for documents called CIDs

00:43:36.000 –> 00:43:41.000
can be issued. Agents review documents and interview witnesses

00:43:41.000 –> 00:43:54.000
Oig, attorneys coordinate with victim agencies like CMS or FDA to make sure that the agency supports the theory of liability the DOJ is pursuing.

00:43:54.000 –> 00:44:09.000
If a case is initiated by a whistleblower, DOJ decides whether to intervene in the litigation, and at the same time, CMS controls the payment and the enrollment, so it can suspend payments or revoke billing privileges, like Kim mentioned earlier.

00:44:09.000 –> 00:44:14.000
CMS has the power to stop money before a case even exists

00:44:14.000 –> 00:44:31.000
And the agencies coordinate the False Claims Act working group that was announced in 2025. They include CMS, OIG, DOJ Civil, and HH, all of these, agencies are working behind the scenes

00:44:31.000 –> 00:44:43.000
and coordinating cases. The takeaway here is the same facts can reach all three tracks and the agencies are talking to one another. Next slide, please

00:44:43.000 –> 00:44:55.000
So let’s start here with the False Claims Act. The False Claims Act at a high level, it creates liability for knowingly presenting a false or fraudulent claim for payment

00:44:55.000 –> 00:45:13.000
So breaking down what’s required, it requires knowledge, falsity, materiality, and damages. I want to focus here on the knowingly piece because so many people have said to me over the years, I didn’t commit fraud. I didn’t, you know, I did not do anything on purpose

00:45:13.000 –> 00:45:32.000
But within the definition of the False Claims Act, knowingly is very deliberately broad. It does include actual knowledge, you know, where you know that you’re doing something wrong, but it also includes deliberate ignorance and reckless disregard. Deliberate ignorance means you’re looking away from a problem that you have reason to suspect is there.

00:45:32.000 –> 00:45:36.000
But you don’t do anything about it

00:45:36.000 –> 00:45:41.000
Looking at the remedies under the False Claims Act, it can be up to 3 times the damages, plus a

00:45:41.000 –> 00:45:44.000
claim civil penalty

00:45:44.000 –> 00:45:55.000
The kickback statute is a criminal statute and it makes a crime to pay or receive anything of value to induce referrals of federal program business.

00:45:55.000 –> 00:46:08.000
Specifically, it’s a criminal law that prohibits knowingly and willfully offering, paying, soliciting, or receiving remuneration to induce a reward federal program referrals

00:46:08.000 –> 00:46:18.000
What’s important there is that there is a liability on both sides of any agreement to, for the arrangement of those services.

00:46:18.000 –> 00:46:30.000
Remuneration is an incredibly broad, and it includes anything of value. It can be leases that are below fair market value, free services, debt forgiveness

00:46:30.000 –> 00:46:43.000
Under the one purpose test, if an arrangement is improper and unlawful, if even one purpose is the intention to induce the referral federal program

00:46:43.000 –> 00:47:00.000
And finally, exclusion. Exclusion is a payment prohibition, and it bars individual and entities from providing services, ordering, furnishing, or providing services that are payable under a federal health care program.

00:47:00.000 –> 00:47:08.000
This exclusion authority is what OIG releases in exchange for compliance agreements, known as corporate integrity agreements.

00:47:08.000 –> 00:47:10.000
Next slide, please.

00:47:10.000 –> 00:47:19.000
So where do the cases come from? There are really three common areas, though of course there are more, but I want to start with data.

00:47:19.000 –> 00:47:35.000
OIG reports data briefs, public Medicare data sets such as utilization and open payment data are mined by DOJ and also by private whistleblowers in order to bring cases to the federal government

00:47:35.000 –> 00:47:44.000
Kim noted CMS has moved away from paying Chase towards AI and data analytics to stop improper payments before they go out.

00:47:44.000 –> 00:48:00.000
Whistleblowers under the False Claims Act, a private whistleblower called a relator, they sue on the government’s behalf. So a complaint is filed under seal, meaning nobody knows about it except the government. So the defendant is also the left to know that they’ve been sued

00:48:00.000 –> 00:48:11.000
DOJ is duty bound to investigate these cases, and if there’s a settlement or a judgment, then the whistleblower is entitled to share a part of that overall recovery.

00:48:11.000 –> 00:48:25.000
And then there’s also priorities of the administration. So, the False Claims Act working group identified six priority areas, including Medicare Advantage, drug device and biological pricing kickbacks

00:48:25.000 –> 00:48:37.000
defective devices, barriers to care and network adequacy, and electronic health record manipulation. Next slide, please.

00:48:37.000 –> 00:48:51.000
So how does the government decide whether it’s civil, criminal, administrative, or sometimes all of the above? Well, it really just depends on the facts and the circumstances, but each of these pathways have different requirements.

00:48:51.000 –> 00:49:05.000
For a criminal case, the government must prove knowing and willful conduct beyond a reasonable doubt. That is a very, very high bar that it has to meet in order to bring a case.

00:49:05.000 –> 00:49:17.000
In my experience, DOJ tends to bring cases where there’s very strong intent evidence of wrongdoing or egregious conduct or a combination of both.

00:49:17.000 –> 00:49:34.000
On the civil side, as I mentioned before, the knowledge standard reaches an intent that is less than that criminal beyond a reasonable doubt, intentional conduct, but more than mere negligence or accidental mistakes.

00:49:34.000 –> 00:49:43.000
Right? So it’s somewhere in between there is what’s required for the civil false Claims Act case

00:49:43.000 –> 00:49:58.000
And again, the remedy is up to three times damages and penalties. And finally, on the administrative side, OIG has CMPs over 40 CMPs and they cover False Claims Act kickbacks, employing excluded people

00:49:58.000 –> 00:50:12.000
failure to return an overpayment, just to name a few. OIG has to prove those cases by preponderance of the evidence and it goes before an administrative law judge when it brings the case

00:50:12.000 –> 00:50:18.000
There is a six-year period, a statute of limitations, and they can often seek exclusion.

00:50:18.000 –> 00:50:34.000
A lot of times these tracks can overlap kickback conduct. I keep talking about that because it’s the perfect example of conduct that raises all three of these liabilities in terms of criminal liability

00:50:34.000 –> 00:50:50.000
liability under the False Claims Act, and also administrative liability. So that’s in that coordination that I talked about at the beginning, where the government is trying to figure out the best track, for… to resolve a particular case.

00:50:50.000 –> 00:50:53.000
Last slide

00:50:53.000 –> 00:51:12.000
So, how are cases resolve? Ultimately, there’s often a settlement or litigation after there’s been an investigation, the government decides whether or not to intervene. If a whistleblower has brought the case and the government declines, the whistleblower can go forward even without the Department of Justice.

00:51:12.000 –> 00:51:22.000
Often settlements are negotiated, settlement agreements and both the government and the relator have a stake in the outcome of those matters.

00:51:22.000 –> 00:51:33.000
The monetary exposure, as I’ve said a couple times under both the False Claims Act and also the OIG CMPs, liability is up to three times the amount of damages

00:51:33.000 –> 00:51:48.000
Self-disclosure, there’s been a lot of new self-disclosure protocols, and a lot’s happened over the last few weeks, but self-disclosures generally can resolve matters with lower multipliers on damages in exchange for cooperation, among other benefits.

00:51:48.000 –> 00:52:05.000
And finally, there can often be a corporate integrity agreement, which is a compliance agreement with HHS-OIG, typically for a period of 5 years at the end of a false claims act settlement. And that is for usually in exchange for OIG’s exclusion authorities

00:52:05.000 –> 00:52:10.000
And OIG monitors compliance, that entity’s compliance with federal healthcare programs.

00:52:10.000 –> 00:52:28.000
I think the big takeaway here is that enforcement is a priority for this administration, and it is intensifying. Dave and driven enforcement and agency coordination appear to be at an all-time high. Thanks for your time.

00:52:28.000 –> 00:52:29.000
Over to you, Luke

00:52:29.000 –> 00:52:31.000
All right

00:52:31.000 –> 00:52:37.000
Great. Good afternoon, everyone. I want to thank the Alliance for inviting me to speak.

00:52:37.000 –> 00:52:40.000
Next slide, please.

00:52:40.000 –> 00:52:44.000
You go to the next slide.

00:52:44.000 –> 00:52:51.000
Okay, collaboration is key. NHCAA, what is it that we do? What’s our purpose?

00:52:51.000 –> 00:52:54.000
To be successful against healthcare fraud

00:52:54.000 –> 00:53:02.000
There has to be collaboration and cooperation between the private and public science. It just makes sense.

00:53:02.000 –> 00:53:04.000
You have Medicare Advantage

00:53:04.000 –> 00:53:16.000
Health plans contracting with the government to provide Medicare services. In the Medicaid space, you had Medicaid managed care companies who are providing Medicaid benefits.

00:53:16.000 –> 00:53:22.000
Across the board, there’s interaction between the private and public side

00:53:22.000 –> 00:53:36.000
It’s just critically important if you’re going to be successful to share information, to bring the payers together, to talk through what’s happening scheme-wise, what’s happening as far as

00:53:36.000 –> 00:53:51.000
Geographically where these schemes are rising, you’ll see that schemes arise in one geographic area, and they travel to other geographic areas. Scheme arises on the private side and a health insurance for a health insurance payer, and then

00:53:51.000 –> 00:54:01.000
gravitates over to Medicare or Medicaid. So that’s why collaboration is key. And what we do is we bring together the payers

00:54:01.000 –> 00:54:06.000
About 95 health insurance companies, virtually the entire

00:54:06.000 –> 00:54:21.000
you know, environment, landscape of health insurance in the United States, and bring together the federal and state partners. On the federal side, FBI, HHS, OIG, CMS, Veterans Health Administration

00:54:21.000 –> 00:54:29.000
The Defense Health Service Administration that provides health benefits for the military and retirees

00:54:29.000 –> 00:54:44.000
On the state side, Medicaid fraud control units, Medicaid program integrity units, you know, the whole gamut of agencies that have some interest with respect to healthcare fraud

00:54:44.000 –> 00:54:53.000
We bring them all together and have them share information. You know, next week we have our annual conference

00:54:53.000 –> 00:55:11.000
And we’ll have about 1,200 folks all together, about 100 of those will be a combination of FBI and HHS OIG agents. And then a good number of state folks as well as the folks from the special investigative units from the health insurance industry.

00:55:11.000 –> 00:55:29.000
So, we bring them all together. And as Leslie mentioned at the beginning, US healthcare system is incredibly complex. If you think of all the payers, then you bring all the providers that are out there, whether it be physicians, whether it be

00:55:29.000 –> 00:55:38.000
Physical therapists, whether it be DME providers, laboratories, whatever it happens to be, you mix all of those up

00:55:38.000 –> 00:55:56.000
In a very complex payment system, and the system does open itself up for fraud, obviously. Now, I’ve been in my position for this is my 22nd year, and I can tell you I’ve seen great progress over the last 22 years

00:55:56.000 –> 00:56:05.000
In the fight against healthcare fraud and Medicare, and also in the other federal and state programs and on the private side as well.

00:56:05.000 –> 00:56:08.000
And we’ll talk a little bit about that. But

00:56:08.000 –> 00:56:15.000
Progress is being made. But again, the complexity of the system just lends itself

00:56:15.000 –> 00:56:18.000
to a potential fraud

00:56:18.000 –> 00:56:32.000
So what I’d like to do next, I was asked to give you some examples of healthcare fraud, how healthcare fraud is committed. And what I did was I basically went back over the past month

00:56:32.000 –> 00:56:44.000
and say, Okay, what kind of cases have been brought? What? What’s out there? You know, what? What are we looking at? This slide just gives you some some idea, but I’m going to take you through some of the cases

00:56:44.000 –> 00:56:46.000
But

00:56:46.000 –> 00:56:56.000
when you talk about healthcare, how is it committed? Well, you have billing for services that were never rendered. You have billing for more expensive services than were actually provided.

00:56:56.000 –> 00:57:11.000
You’re performing medically unnecessary services solely for the purpose of generating insurance payments. You have misrepresenting non-covered treatments as medically necessary covered treatments

00:57:11.000 –> 00:57:24.000
For example, you know, cosmetic surgeries being billed as something other than cosmetic surgeries. Falsifying a patient’s diagnosis and medical record to justify tests and other treatment

00:57:24.000 –> 00:57:34.000
And then kickbacks. You’ll see in the larger healthcare fraud cases, kickbacks are more often than not a part of those cases.

00:57:34.000 –> 00:57:50.000
some sort of kickbacks are being provided. So let me just take you through some cases just that I’ve become aware of over the last month to give you a feel for some of these things that we’ll talk about on durable medical equipment, telemarketing schemes

00:57:50.000 –> 00:57:55.000
laboratory testing schemes, genetic testing

00:57:55.000 –> 00:58:03.000
There was a chiropractor who was sentenced to 14 years in federal prison for his role in a $30 million health care fraud scheme involving Medicare.

00:58:03.000 –> 00:58:19.000
The authorities said this particular individual paid more than $1 million in kickbacks to marketers, supposed telehealth companies, and a call center which encourage enrollees to share personal information, agree to equipment they didn’t need

00:58:19.000 –> 00:58:29.000
The conspirators bought sham doctor’s orders for orthotic braces, contiguous glucose monitors, and other equipment

00:58:29.000 –> 00:58:46.000
Another case, again, this is just in the last less than really less than a month. Two Pakistani nationals charged with 3.5 million Medicare fraud scheme. Again, both these individuals, these two in California have been charged with healthcare fraud and identity theft in connection with a Medicare scheme

00:58:46.000 –> 00:59:02.000
Involving fraudulent claims for durable medical equipment. They’re accused of creating shell companies that appear to be actual DME companies to submit more than 3.5 million fraudulent claims with proceeds sent to contacts of Pakistan

00:59:02.000 –> 00:59:26.000
Point about this is we’ve seen in big healthcare fraud cases that some of this moment, money does go overseas that’s stolen from Medicare program. This case happened to be two Pakistanis, but it’s not just Pakistan, other international organizations are involved in healthcare fraud

00:59:26.000 –> 00:59:38.000
Another case, the owner of Health Splash was sentenced to 19 years in prison for orchestrating a $1 billion scheme that defrauded Medicare and other federal programs.

00:59:38.000 –> 00:59:47.000
This individual and his co-conspirators targeted hundreds of thousands of Medicare beneficiaries using call centers and generated false doctor’s orders

00:59:47.000 –> 01:00:01.000
And prescriptions through an internet platform to convince beneficiaries to accept medical equipment they didn’t need. The program Medicare paid more than 450 million for the claims

01:00:01.000 –> 01:00:11.000
Now, you may wonder where these physician orders come from. Some of them are stolen identities of physicians and forged

01:00:11.000 –> 01:00:29.000
But here’s a case where a psychiatrist living in Georgia was sentenced to a year and a day in prison for his role in a $1.9 million Medicare fraud scheme. Powell signed medically unnecessary orders for braces for more than 500 beneficiaries without examining patients, enabling suppliers to submit 1,400 false claims

01:00:29.000 –> 01:00:39.000
So that gives you an idea. Here’s a psychiatrist that was signing orders for unnecessary equipment

01:00:39.000 –> 01:00:54.000
On the testing side, just recently, an individual from Annapolis, Maryland, right here in the DC area, he was providing testing, COVID testing and different testing for nursing home

01:00:54.000 –> 01:00:57.000
Residents.

01:00:57.000 –> 01:01:12.000
He learned that the money as well, so he billed Medicare $18.7 million for unnecessary and non-existent respiratory tests involving nursing home residents. Medicare paid more than $7.2 million of those claims.

01:01:12.000 –> 01:01:16.000
Again, you know, just just an example.

01:01:16.000 –> 01:01:27.000
And then there was a big takeout just last week, the Justice Department HHS-OIG, FBI made had a takedown out in the LA area

01:01:27.000 –> 01:01:45.000
And there was a physician who was working with a chiropractor and the chiropractor was telling patients basically that he was a doctor when he wasn’t, and then referring it the patients to another, to an actual doctor

01:01:45.000 –> 01:01:53.000
cardiothoracic surgeon who was then performing unnecessary atherectomies on these patients.

01:01:53.000 –> 01:01:56.000
Okay, so they’re actually performing

01:01:56.000 –> 01:02:01.000
Invasive procedures on patients that did not need the procedures

01:02:01.000 –> 01:02:15.000
and charging Medicare for those services. So you get, you know, we always talk about the money that’s involved in healthcare fraud. Obviously, patient harm is another big aspect of that

01:02:15.000 –> 01:02:24.000
And these individuals have just been arrested. They haven’t been tried yet. So they’re presumed innocent until found guilty. But

01:02:24.000 –> 01:02:33.000
You know, just giving you an example of the type of things that happen out there. So last slide, please.

01:02:33.000 –> 01:02:48.000
So again, the prevention mindset, everyone has mentioned that that’s key. That’s when I talk to our members on the commercial side, the folks that head up the Special Investigation Units.

01:02:48.000 –> 01:02:51.000
Everything has to be prevention.

01:02:51.000 –> 01:02:57.000
And that has to be the real focus. And the slide just before this, I think we went through

01:02:57.000 –> 01:03:02.000
Real quick, if we just bring that one up, the one before this one

01:03:02.000 –> 01:03:13.000
Artificial intelligence, big, big issue in healthcare fraud known only as a tool for detecting and preventing healthcare fraud, but also for committing healthcare fraud.

01:03:13.000 –> 01:03:21.000
And we’ve done a paper on that. We have a subcommittee that has done a issue brief on that for our members

01:03:21.000 –> 01:03:36.000
the importance that artificial intelligence is going to play across the spectrum with respect to healthcare fraud, both on the positive side of detection and also on the negative side of committing healthcare fraud.

01:03:36.000 –> 01:03:45.000
So my time is up, so I’ll go ahead and turn it over to our next speaker. Thank you.

01:03:45.000 –> 01:03:52.000
And we’re pleased to hear from Lindsey, who will talk to us about the beneficiary perspective

01:03:52.000 –> 01:04:09.000
Hi all and thanks for being here today and for the opportunity to speak with y’all. I’m the Federal Policy Director for the Medicare Rights Center, and we’re a national nonprofit consumer services organization that works to ensure access to affordable health care for older adults and people with disabilities through

01:04:09.000 –> 01:04:25.000
counseling and advocacy, educational programs, and public policy initiatives. The heart of our work really is our free national helpline, where we help people with Medicare and their caregivers and others understand and navigate the program. So, all of our work really stems from our direct

01:04:25.000 –> 01:04:41.000
connection to beneficiaries. And so with that in mind, I’ve been asked to speak about what good program integrity looks like from the beneficiary perspective. And to get there, I think we first need to consider what fraud looks like from their point of view.

01:04:41.000 –> 01:05:00.000
And, you know, as we’ve just heard, Medicare fraud, waste, and abuse is not just about federal budget problems. They can affect people’s health, finances, not to minimize those problems, they’re big, but they can also affect people’s health, finances, time, independence, and confidence in the program. And how people interface with those abuses can vary

01:05:00.000 –> 01:05:16.000
At Medicare Rights, we do hear from people who’ve been billed from services they didn’t receive, are getting repeated intrusive offers for tests they don’t need, or are sent equipment they didn’t order. Others have undergone unnecessary medical intervention, exposing them to really serious health risks

01:05:16.000 –> 01:05:31.000
And this can all cause a lot of distress and confusion. People may receive very hard to understand notices, worry about the security of their personal information and the consequences of unwarranted procedures, or have difficulty determining where to go for help.

01:05:31.000 –> 01:05:50.000
Withholding care is also problematic. When needed services are wrongly denied, it can lead to worse outcomes and higher costs. It can also force people into an overly complex appeals process. And these are burdens that accrue even if the denial is eventually overturned. Even successful appeals come at a cost.

01:05:50.000 –> 01:06:05.000
While beneficiaries may clock these in other situations, they may not always equate them with fraud. And some schemes may go undetected altogether. Not everyone’s going to encounter an access problem following a misuse of their Medicare information, for example

01:06:05.000 –> 01:06:23.000
But others will have fallout. And whenever exploitation occurs, the harms can compound. This is particularly true for people who are already struggling to navigate the system. Maybe they’re managing multiple or complex health conditions or cognitive impairment, or have few providers in their community

01:06:23.000 –> 01:06:27.000
These are folks that may just have the hardest time successfully resolving a problem.

01:06:27.000 –> 01:06:35.000
So how do we design a system that appropriately reflects and responds to these experiences? Next slide, please.

01:06:35.000 –> 01:06:54.000
So we’ve developed some principles to help conceptualize the idea of good program integrity from the beneficiary perspective. And we’re suggesting it should do four things. Protect beneficiaries, preserve access to care, maximize trust and minimize burdens. Essentially, the beneficiary impact should be a core measure of success.

01:06:54.000 –> 01:07:15.000
And I’ll just walk through these briefly. So the first responsibility of program integrity is to prevent people from taking advantage of Medicare and those who depend on it. So this means identifying suspicious billing, addressing problematic marketing, preventing the misuse of beneficiary information, and holding bad actors accountable

01:07:15.000 –> 01:07:20.000
But it also means looking beyond the claim itself to the beneficiary experience

01:07:20.000 –> 01:07:27.000
Did somebody receive care they didn’t need? Were they misled about a service? Was there personal information misused?

01:07:27.000 –> 01:07:44.000
In other words, detecting a dubious pattern of medical equipment claims is really valuable, but the beneficiary perspective response kind of goes beyond that to also consider how they were impacted, whether they were sent equipment they never requested, and, you know, what’s going on with their personal information

01:07:44.000 –> 01:07:49.000
Whether they needed help reaching a resolution and whether that help was available.

01:07:49.000 –> 01:08:04.000
The second principle is around access to care, and we’d suggest that a program integrity intervention is not fully successful if it reduces improper payments, but also prevents people from receiving appropriate care. This could happen if it creates

01:08:04.000 –> 01:08:19.000
unnecessary delays, blocks illegitimate provider’s ability to deliver care, or makes it difficult to remedy a mistake in denial. In those instances, the beneficiary is the one that’s going to pay the price. They may have to postpone treatment, untangle rolls of red tape

01:08:19.000 –> 01:08:22.000
or go without needed services while the issue gets resolved

01:08:22.000 –> 01:08:37.000
So a beneficiary centered strategy should really minimize this risk. For example, by ensuring the program integrity intervention is appropriately targeted, includes timely ways to correct mistakes and monitors for unintended consequences.

01:08:37.000 –> 01:08:50.000
Third is build and maintain trust. So beneficiaries should be able to trust that Medicare is paying for appropriate services and protecting them and that the program will take action when someone tries to exploit it.

01:08:50.000 –> 01:09:07.000
When beneficiaries have confidence in Medicare, they’re more likely to feel safe using their coverage, which is good across the board as it promotes health and well-being, and provided there’s a streamlined way to do so, it also may make them more likely to report concerns, including fraud and suspicious activities

01:09:07.000 –> 01:09:22.000
Because they trust that those claims will be taken seriously. And getting there, in part, depends on how Medicare responds when a problem does occur. Can beneficiaries understand what happened? Do they know who to contact? Did they receive a timely and understandable response?

01:09:22.000 –> 01:09:30.000
So clear communications, accessible reporting channels, and reliable follow-up all help build clear trust.

01:09:30.000 –> 01:09:47.000
The last pillar is on minimizing beneficiary burden, and while having these accessible ways to report concerns is important, the responsibility for detecting, investigating, and addressing fraud really belongs to the organizations that are equipped and authorized to do that work.

01:09:47.000 –> 01:09:54.000
Beneficiaries cannot be expected to catch and unravel sophisticated and unsophisticated fraud schemes themselves.

01:09:54.000 –> 01:10:14.000
As I mentioned earlier, they may not even know that the fraud has occurred, and when it’s done, you know, well, they often don’t. And even when they do, not all beneficiaries are going to have the bandwidth to carry the administrative weight of of untangling it. For some, even a seemingly small administrative hurdle can really be significant, you know, particularly those with

01:10:14.000 –> 01:10:20.000
High care needs, limited English proficiency, or minimal access to digital tools.

01:10:20.000 –> 01:10:32.000
a confusing letter, an unfamiliar billing code, a request to repeat information they’ve already submitted can really create substantial staff and substantial stress and effort

01:10:32.000 –> 01:10:47.000
So, we’d really encourage you to ask, you know, how much work a potential intervention creates for beneficiaries, and whether there are alternatives. You know, for example, can Medicare use information that already has rather than asking people to provide it again

01:10:47.000 –> 01:10:54.000
Our beneficiary-facing notices written in plain language, and can they resolve problems by phone as well as online?

01:10:54.000 –> 01:10:57.000
Next slide.

01:10:57.000 –> 01:11:03.000
So I walked through this a bit already, and in the interest of time won’t do so

01:11:03.000 –> 01:11:15.000
Really again here, but this slide really is intended to illustrate that these principles translate into practical policy evaluation and oversight questions that could be helpful when reviewing proposed interventions.

01:11:15.000 –> 01:11:18.000
Next slide, please.

01:11:18.000 –> 01:11:32.000
And to conduct those reviews in a systematic way, we’d suggest coupling the questions with specific outcome measures. This is in addition to tracking financial and enforcement measures like improper payments

01:11:32.000 –> 01:11:42.000
is achieved. Alongside it, we think, you know, also tracking things like beneficiary complaints, care disruptions, erroneous denials and resolution times.

01:11:42.000 –> 01:11:49.000
And that in so doing, we meaningfully expand the definition of success to include outcomes that matter to beneficiaries.

01:11:49.000 –> 01:11:53.000
Next slide

01:11:53.000 –> 01:12:10.000
So Medicare program, then we get to kind of what does success look like overall. Medicare program integrity is essential to its long-term sustainability and every dollar lost to fraud or unnecessary spending is a dollar that cannot be used as effectively as it should be. And that’s a really important thing to track and measure

01:12:10.000 –> 01:12:27.000
At the same time, beneficiaries experience program integrity through real-world interactions, whether the equipment they need arrives, whether a claim is accurate, whether their personal information is protected, whether a decision is fair, and whether someone helps them when something goes wrong

01:12:27.000 –> 01:12:40.000
And a strong program integrity system recognizes both sets of objectives. It prevents wrongdoing, protects public resources, and ensures Medicare works better for beneficiaries now and in the future.

01:12:40.000 –> 01:12:44.000
And with that, I’ll turn it back over.

01:12:44.000 –> 01:13:00.000
Thank you so much, Lindsey. Thank you to the panel. We have had an active participants who’ve sent in a number of questions and so we’re going to get right down to it. I’m going to ask you all to keep your questions really crisp

01:13:00.000 –> 01:13:11.000
Like you were testifying before a congressional hearing. Let’s start with a question about the scope and scale of fraud in the Medicare program.

01:13:11.000 –> 01:13:23.000
Do we know what… what the estimate for fraud is in the Medicare program, and what are the systems in place to prevent it?

01:13:23.000 –> 01:13:32.000
I guess I can go first on that one, since I’m the Medicare person. So I think Medicare itself is a little hard to put out, but we

01:13:32.000 –> 01:13:54.000
Medicare, Medicaid, and Marketplace programs, it’s about $100 billion out of the nearly $2 trillion that we cover. So it’s, I’d say true fraud is probably about a third, a third, you know, 35 to $40 billion. Again, I know you all at GEO have looked at this as well, Leslie, so it’s a little

01:13:54.000 –> 01:13:55.000
That’s hard

01:13:55.000 –> 01:13:58.000
It’s hard to major because you don’t know it until you actually find it, so it’s really hard. But

01:13:58.000 –> 01:14:21.000
I think we use a multi-pronged approach. We look at improper payments, which we work very closely with GAO and OAG on to try and reduce improper payments, which is things like inappropriate documentation, billing for the wrong thing, you know, billing it more than you should, you know, that kind of thing. And then we go after the real fraud using the tools I talked about earlier, a lot of the analytics tools and a lot of the administrative tools

01:14:21.000 –> 01:14:41.000
To really try, in our case now to stop the fraud before it goes out the door, and then partner with our law enforcement partners to actually try and recoup anything that actually does get out. So I’m hoping those numbers, that $100 billion, even the 35 to 40 billion, will go down. As a final point, just to keep it crisp, last year, our return on investment

01:14:41.000 –> 01:14:57.000
was $22.3 for every dollar that taxpayers invested. So that’s just on, you know, for fiscal year 25 alone, we had recoveries of $41.9 billion, of which 68% of that was dollars that were stopped from going out the door

01:14:57.000 –> 01:15:06.000
So we’re making strides, but we’ve got a long way to go. So it’s not a perfect answer because there is no perfect answer, but that’s the best guess that I’ve got.

01:15:06.000 –> 01:15:19.000
Thanks, Kim. And I just want to chime in that GEO’s report on the data analytics that CMS is using for the Medicare program, we found that they are on par with what the private sector is doing.

01:15:19.000 –> 01:15:36.000
The next question is about is CMS looking at leveraging other transaction authority similar to what the Department of War is doing to procure proof of concept for innovation in AI products and reducing fraud, waste, and abuse

01:15:36.000 –> 01:15:39.000
And improve speed to market.

01:15:39.000 –> 01:15:56.000
So we have been very innovative. We’ve done a couple of different things. We did last year a chili cook-off, as we called it, which was we had over 250 vendors that participated with us to show us what their best things were in terms of machine learning, artificial slash superintelligence

01:15:56.000 –> 01:16:13.000
Etc, so that we could really see what the different things were out there. And then the top 10 were ones that we partnered with in various forms to be able to try different things. We continue to do a number of pilots. We currently have 6 state pilots underway, including Oracle in Indiana

01:16:13.000 –> 01:16:15.000
And Centrelink in Florida

01:16:15.000 –> 01:16:30.000
Where we’re testing different concepts to look at real CAI claims data in ways that is innovative. So we’ve we are constantly looking at how it is that we we haven’t tried new procurement authorities per se, but we have been using a lot of new and innovative ways to actually get

01:16:30.000 –> 01:16:45.000
Access to the people, and we continue to do, I personally, in the 2 years that I’ve been back now, have met with probably well over 200 different vendors who have all told me, ironically, they can all save us $2 billion. Every single person can save us

01:16:45.000 –> 01:17:02.000
But, you know, some of those have been more successful than others, but it is really great to be able to use a lot of these new flexibilities to try and see what kind of options are out there and to give people pilots another chances to show us what they can do

01:17:02.000 –> 01:17:17.000
Thanks. I have a question for Lisa and one sort of more focused on the beneficiary side of things and then a data sharing question for all the panelists, just to give you a heads up where we’re going. So Lisa, we’ve talked about how the federal government works

01:17:17.000 –> 01:17:22.000
And we’ve heard from physician and providers. You mentioned compliance

01:17:22.000 –> 01:17:33.000
Can you talk about the role private organizations play in setting clear expectations about compliance and what it takes to make compliance program actually work inside an organization?

01:17:33.000 –> 01:17:50.000
Yeah, so I will say this after having seen hundreds of compliance programs, I’m really convinced that what actually moves the needle with respect to compliance is commitment and tone at the top. In the end of the day, all the things I’m going to talk about in just a minute

01:17:50.000 –> 01:18:09.000
In the end, it comes down to whether or not that is that cultural commitment to really ensuring that your organization is compliant. I think big picture, that the best thing, investment that any company can make right now in the healthcare industry is to guard against fraud risk is investing in their compliance program

01:18:09.000 –> 01:18:27.000
you know, DOJ and OIG both have invaluable resource guidance that they’ve issued over the years. Oig has a long history of issuing guidance, and it keeps coming. They’ve recently updated some industry-specific guidance, and I think more is forthcoming

01:18:27.000 –> 01:18:44.000
And paying attention to what OIG is auditing, what they’re evaluating, looking at recent false Claims Act settlements and C&P settlements, study integrity, corporate integrity agreements, and whatever industry it is that you… where you sit, can really help ensure that you’ve got a really robust

01:18:44.000 –> 01:19:01.000
risk assessment, as part of your compliance program. And finally, you can consult with a compliance expert to make sure that they can help you come in and give an objective look to potentially identify any compliance gaps that you may have.

01:19:01.000 –> 01:19:12.000
Thanks for that. I have a question about the beneficiary’s role and the use of EOBs. So explanation of benefits

01:19:12.000 –> 01:19:37.000
For people with many services, it’s hard to keep track of visits and services and the use of an explanation of benefits as a review and leaning on beneficiaries to really carefully review those and know what they’re looking at. Have there been any studies or efforts to make this potentially valuable oversight tool more effective? And I don’t know if Lindsey, you want to comment on it, maybe other panelists have something they want to say about

01:19:37.000 –> 01:19:41.000
The use of the AOB and that as an oversight

01:19:41.000 –> 01:19:48.000
I’m not sure about studies off the top of my head, but I certainly do think that it is

01:19:48.000 –> 01:20:04.000
Not a great strategy as a, you know, if that’s all we’re relying on, is just for beneficiaries to really pour through their EOBs and then to, you know, funnel those, anything that they may notice up to the top and hope that it gets to the right people and in a timely way. You know, this can just… it can be a lot of information that’s overwhelming

01:20:04.000 –> 01:20:09.000
And again, you know, it’s not always clear

01:20:09.000 –> 01:20:28.000
where, you know, is this… is this a misprint? Is this, you know, something that’s actually wrong? Surely if, you know, my Medicare information had been compromised or stolen, this isn’t how I would be hearing about it. I’d be hearing about it in some other way. And so there’s just a lot that goes, into reviewing that information from

01:20:28.000 –> 01:20:37.000
The beneficiary perspective that may not necessarily automatically go fraud, and then may not automatically go, well, where do I go with this information as well?

01:20:37.000 –> 01:20:41.000
Hey Leslie, this is Bartley. Can I jump in?

01:20:41.000 –> 01:20:46.000
So I kind of agree with Lindsey, but not exactly just for

01:20:46.000 –> 01:20:48.000
A joust.

01:20:48.000 –> 01:20:51.000
I think that generally

01:20:51.000 –> 01:20:57.000
Patients need to think about we should be conscious of trying to teach our patients to be

01:20:57.000 –> 01:21:14.000
Good consumers of healthcare. We don’t typically, I think, across our nation particularly. And the EOB is a good way to be a healthcare consumer. There’s stuff you can do before the service as well. And I totally agree with you, Lindsey, that they’re not the front line. They can’t possibly know enough in this massively complex industry.

01:21:14.000 –> 01:21:20.000
But I do think that we all, Medicare in particular, because Medicare is such a large payer

01:21:20.000 –> 01:21:24.000
Should make increased efforts to

01:21:24.000 –> 01:21:43.000
Educate the patient about this healthcare system. I’m reasonably knowledgeable about the healthcare system. I get EOBs sometimes that are incomprehensible because they don’t allow me to understand what someone’s actually billing for, even though I understand it. And so I think that there’s an opportunity to educate the consumers of healthcare

01:21:43.000 –> 01:22:03.000
About what and how healthcare expense happens because ultimately they’re paying for it as well as in fraud, of course, is just a small piece of that

01:22:03.000 –> 01:22:04.000
I think you’re muted, Leslie.

01:22:04.000 –> 01:22:22.000
Sorry, yeah, thanks. We have a question about data sharing. What impediments do you see to data sharing that would enable better identification and prevention of improper payments? And this is to all the panelists.

01:22:22.000 –> 01:22:27.000
From our perspective at NHCAA, I mean, we

01:22:27.000 –> 01:22:39.000
How commercial side members share a lot of information with the public side. So there’s a database of investigations that we have

01:22:39.000 –> 01:22:53.000
So if, say, UnitedHealthcare opens an investigation with respect to a provider that’s in a database, that database is searchable not only by the other commercial side payers, but also from the public side

01:22:53.000 –> 01:23:03.000
So, you know, it’s just, and we also bring people together and they share information about what they’re seeing in the last week

01:23:03.000 –> 01:23:20.000
You know, it’s data in a sense, it’s not electronic data, but it’s also data in the sense that, okay, we’ve just opened a case with respect. We’re starting to see fraud with DME companies in this particular geographic area, giving everybody notice of that

01:23:20.000 –> 01:23:24.000
There’s also the healthcare fraud prevention Partnership

01:23:24.000 –> 01:23:29.000
which is run, overseen by Cms

01:23:29.000 –> 01:23:35.000
And that brings certain partners that want to share actual sharing claims data

01:23:35.000 –> 01:23:49.000
To be analyzed on an aggregated basis among those partners to look for different patterns and things. So that’s another project that started a good number of years ago and is still advancing.

01:23:49.000 –> 01:24:05.000
And again, that’s private side and Medicare data. Again, the interaction between the 2 is and the importance of looking at it as an integrated type of system is really, really important.

01:24:05.000 –> 01:24:09.000
Thank you. Does anyone else want to join in on this data sharing impediment?

01:24:09.000 –> 01:24:28.000
I think, there’s a couple of things that we run up to. You know, there’s a lot of privacy act and HIPAA issues that we run up against, depending on who we want to share with and how, and we have to constantly be talking with our legal counsel about what we can do, even with other government entities. We are currently

01:24:28.000 –> 01:24:43.000
In a bit of a tussle with another large government entity about whether we can give them data to help them do some fraud and abuse detection, even though they’re another federal agency. They are not a HIPAA covered entity for purposes of this. And so we run up against HIPAA

01:24:43.000 –> 01:25:03.000
We also, a couple of other ones that are ones that we frequently come across are 42 CFR Part 2, which is the substance use disorder records that remains even with some of the recent rulings, it remains a problem because a lot of the fraud is like through sober homes and addiction treatment, lab testing, things like that, which can all

01:25:03.000 –> 01:25:22.000
brush up against those types of issues. And then lastly, for us, the biggest thing is computer matching and privacy protection act. That’s probably our biggest single drag on federal to federal and federal to state data sharing. We have to be able to have a data integrity board approve the agreement

01:25:22.000 –> 01:25:28.000
We need to have a notice in due process. It just takes time. I mean, there are ways to do it, but these are

01:25:28.000 –> 01:25:46.000
That, you know, absent the HFPP, which Louis was talking about, I mean, the fact of the matter is, otherwise it can take as much as 18 months sometimes to get some of these things negotiated, which if you’re looking to get data fast, that’s not fast

01:25:46.000 –> 01:26:02.000
Thank you. We have just five minutes left with our audience and so many questions to cover, so I’m going to go to a big more conceptual question. If you were designing Medicare’s approach to preventing fraud, waste, abuse from scratch, what are the key

01:26:02.000 –> 01:26:11.000
Policy considerations and trade-offs. Would you want policymakers to understand?

01:26:11.000 –> 01:26:12.000
Okay

01:26:12.000 –> 01:26:30.000
Oh, I’ll go first. I have two specific ones that I feel very strongly about. And these are Kim Brandt personal opinion, not that of CMS necessarily. But number one, Medicare is in any willing provider. It should not be in any willing provider anymore. Our number one problem is unless you literally don’t meet the basic requirements

01:26:30.000 –> 01:26:47.000
We have to let you in. And that is what causes so much of the things I was talking about with the moratoriums and some of the stuff earlier. If we had more ability to kick people out and not let them in, that would be huge. But that is not the way the statute is written. That is not the way the program is designed. So that’s a big one

01:26:47.000 –> 01:27:05.000
The second is claim submission window. People have up to a year to submit a claim, and that is something which there are many reasons for that, and some people might need that in certain types of instances. Not everyone needs that, and that is the single biggest way that people manipulate and game the system

01:27:05.000 –> 01:27:18.000
So if there were ways that we could shorten the claim payment window and make it so that we had more control over who we let in, both of those things would significantly reduce a lot of the bread and butter fraud that we see in the program.

01:27:18.000 –> 01:27:19.000
Thank you. Who’s it

01:27:19.000 –> 01:27:26.000
I agree 100% with Kim on any willing provider issue. I mean, if you’re going to redesign the entire program

01:27:26.000 –> 01:27:41.000
Before somebody comes into the program, you need to do background checks, all sorts of things that need to be done. Some of the folks I mentioned in some of the cases I read had already been convicted of crimes and they were back

01:27:41.000 –> 01:27:54.000
Somehow, getting back into the system. So yeah, any willing provider thing, I think if you had to do it over again, that would be a key piece there.

01:27:54.000 –> 01:27:58.000
Other comments, other thoughts

01:27:58.000 –> 01:28:05.000
Well, this is Bartley. This is not so much of a rebuild it, but I do think that

01:28:05.000 –> 01:28:11.000
You know, the concerns about people getting caught in the system who have real needs

01:28:11.000 –> 01:28:12.000
is one that

01:28:12.000 –> 01:28:27.000
needs to be thought about as we think about all the things that are wrong with it, and I do think that some of the things that Kim and Lou talked about of any willing provider, you know, there need to be good authorities given to entities like CMS and others

01:28:27.000 –> 01:28:33.000
Patients do get caught in the middle. Doctors do get caught in the middle, and, you know, we need

01:28:33.000 –> 01:28:49.000
A way to have a quick and effective appeals process. So, you know, Kim, I don’t know, I think in the recent CMS authority to exclude providers, clinicians from the CMS program, I thought I read, and I haven’t read the regulation

01:28:49.000 –> 01:28:51.000
that there really is no

01:28:51.000 –> 01:29:04.000
process that CMS has the authority to just do it based on suspicion. That is good and bad, and if we don’t pay attention to the bad, we really risk in this

01:29:04.000 –> 01:29:12.000
fervor right now to go after the 30 or $100 billion that we… we cause some harm that we don’t want.

01:29:12.000 –> 01:29:22.000
Thank you. Lisa, Lindsey, any last words on this issue? What would you reform? What would you improve?

01:29:22.000 –> 01:29:23.000
Oh, it’s true.

01:29:23.000 –> 01:29:31.000
Yeah, I think, you know, as I mentioned, just making sure that the beneficiary perspective and what matters to them is also being tracked and integrated into the system.

01:29:31.000 –> 01:29:32.000
Yeah, I mean, I think

01:29:32.000 –> 01:29:44.000
in the end of the day, what we’re really looking for here is, you know, making sure the recommendations are implemented. You know, there’s so much cost savings that have, you know, that OIG has

01:29:44.000 –> 01:30:03.000
suggested over time, and there’s been reasons, you know, that it hasn’t been implemented, but I think that there’s a lot of recommendations that have been made by both GAO and OIG that have not yet been implemented that really would need to be considered, in terms of, you know, revamping the whole… if you were revamping the program.

01:30:03.000 –> 01:30:07.000
Over to Alliance staff to wrap us up

01:30:07.000 –> 01:30:23.000
Thank you so much, Leslie, and thank you to all of our incredible speakers for sharing your insights with us today. And thank you to all of you in the audience who made the time to join us. You’ve asked some terrific questions, and now we have a few questions for you. So we really do take listening seriously at the Alliance

01:30:23.000 –> 01:30:39.000
Your feedback will help shape the topics we explore and how we design these programs, so please take a minute to share your thoughts while I walk us through a few final announcements. And if we didn’t get to your question today, please be sure to share it in the feedback form or email us at info@allhealthpolicy.org

01:30:39.000 –> 01:31:01.000
And we’ll do our best to connect you with additional information and resources. Of course, none of this work happens without the partners who make it possible, so a very special thank you again to our sponsor, AARP, for supporting today’s conversation. We’re so grateful to work with organizations that recognize the value of trusted nonpartisan health policy education and help us create spaces like this one for the policymaker community.

01:31:01.000 –> 01:31:21.000
As a reminder, a copy of today’s slides and a recording of the webinar will be available on the Alliance website. We also encourage you to explore the expert and resource list accompanying this webinar, which includes AARP’s newly released resource, Medicare Fraud Hurts Older Adults Access to Care and Financial Security, along with other helpful materials

01:31:21.000 –> 01:31:38.000
to deepen your understanding of Medicare fraud. We’ll share these links via email after today’s event and encourage you to follow us on LinkedIn or join our email list for future updates and resources. And before we officially close, I wanted to highlight another opportunity to continue learning and engaging with the Alliance

01:31:38.000 –> 01:31:53.000
On Thursday, November 12th, we’re hosting our annual Health Policy Forecast Symposium here in DC, exploring what the election results could mean for health policy in the year ahead. The symposium is sold out, but you can still sign up for the waitlist, and tickets are still available for our reception, and we’d love to see you there.

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And on Monday, November 16th, we’re hosting a policymaker community reception in the Rayburn foyer to celebrate our 2026 Congressional Fellows and bring together health policy leaders to join us in doing that. So all congressional staff are welcome. We’d love to see you there

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and applications and nominations for our 2027 fellowship will open next month, so please stay tuned for updates, including an announcement with that news and a forthcoming announcement on our upcoming Cell and Gene Therapy webinar in December. So that concludes today’s webinar. Thank you again for joining us, and we look forward to seeing you at future Alliance events.