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CMS helps to end fraud scheme valued at $1.7 billion in fraudulent claims

Multi-agency collaboration ends one of the largest orthotic fraud schemes to date

CMS worked closely with the Department of Justice, Health and Human Services-Office of Inspector General, and the Federal Bureau of Investigations to end this fraud scheme, which involved Durable Medical Equipment supply companies. These companies were soliciting beneficiaries through robocalls and allegedly paying doctors to write prescriptions for “free” medical equipment, like a back or knee brace – ultimately to be billed to and paid by Medicare - without any patient interaction or with only a brief telephone conversation with patients they had never met or seen.

“In this case, CMS has taken swift administrative action and has suspended payments to 130 distinct providers, thereby likely preventing billions of additional dollars in losses. CMS remains committed to protecting the millions of beneficiaries we are honored to serve and to preventing fraud of all sorts in the Medicare and Medicaid programs,” said Deputy Administrator and Center for Program Integrity Director Alec Alexander.

Read more about the investigation.


CMS contributes to largest ever prescription drug enforcement effort

Collaboration helped stop providers involved in the illegal prescribing and distributing of opioids

As part of the Appalachian Regional Prescription Opioid (ARPO) Strike Force, CMS played an important role in stopping providers involved in the illegal prescribing of opioids and other dangerous narcotics by implementing numerous administrative actions in support of law enforcement.

“Nowhere is this collaboration more important than in our fight against the opioid crisis in America. This is one of the President’s highest priorities and we are proud to be an important part of the largest prescription opioid enforcement effort ever undertaken. We will continue to work tirelessly through investigation, data coordination and administrative action to protect the health and wellbeing of all Americans,” said Deputy Administrator and Director of Center for Program Integrity Alec Alexander.

Read more about the investigation.


Celebrating one year of CMS’ Medicaid Program Integrity Strategy

CMS has taken significant steps to address the challenges of preventing improper payments in the Medicaid program.

In June 2018, CMS implemented a Medicaid Program Integrity Strategy with new and enhanced initiatives to protect taxpayer dollars across states. These include stronger audits and oversight functions, increased data sharing and partnerships, and additional education, technical assistance, and collaboration. Learn more about the progress made and what is upcoming:
Year at a Glance.

Targeted Probe and Educate

Simplifying the Medical Review Process

Our Targeted Probe and Educate (TPE) video explains this streamlined medical review process.

Have you seen our TPE video? The Targeted Probe and Educate (TPE) medical review process helps CMS and providers work together to improve medical claims by avoiding and correcting, through individualized education sessions, many common billing mistakes. Watch this 5 minute video to learn more.

TPE Information

CPI Works to Reduce Burden on Providers

Spend more time with your patients, less on Medicare documentation.

Making the medical review process easier to understand and simplifying documentation are two CPI initiatives aimed at reducing burden on providers. We recently updated our website to help explain the medical review process called Targeted Probe and Educate (TPE), and to describe the work we’re doing to simplify documentation requirements.

Market Saturation Image

Mapping Market Saturation

We’ve updated the market saturation tool with even more data.

CPI’s market saturation tool shows the relationship, in population, between providers and beneficiaries within a chosen geographical location. How many home health providers are located in your zip code? What is the average number of physical & occupational therapy patients per provider in your county? Use the map to answer questions about the availability of care and the use of selected services, by population.

HFPP Partners

Healthcare Fraud Prevention Partnership (HFPP) Continues to Grow

Collectively their membership represents 74% of covered lives in the United States.

Over the last few months, the HFPP has gained several new members including: AIRIO Health Plan, Blue Cross Blue Shield of Arizona, District of Columbia Department of Health Care Finance, Care N’ Care, Louisiana Office of Attorney General – MFCU, and Vision Service Plan. They, along with over 100 other organizations, now enjoy the benefits that this voluntary, public-private partnership provides. Should your organization consider joining others from across the federal government, state and local government agencies, law enforcement, private health insurance plans, employer organizations, and healthcare anti-fraud associations to identify and reduce fraud, waste, and abuse across the healthcare sector? Watch this video to see what current members have to say about this unique and collaborative data-sharing partnership.


Connect with CPI as we host or attend various events throughout the year, join the conversation on Twitter around subjects that matter to all of us, or find the most appropriate vehicle to report suspected fraud, waste or abuse.