Change coming after ProPublica shows fake doctors billing insurance

Earlier this year, the nonprofit investigative newsroom ProPublica published an investigation into a “gaping loophole” in health care law. ProPublica highlighted the story of a Texas personal trainer with a felony conviction who simply lied to the government when he applied for several National Provider Identifiers (NPI), which are the numbers required by the Centers for Medicare & Medicaid Services before healthcare providers can bill insurance companies.

He simply said he was a licensed physician. Nobody checked with the state licensing board.

That lack of verification made it easy for the man to collect at least 20 NPIs and bill insurance companies for more than $25 million in bogus claims over four years.

According to ProPublica, he succeeded in bilking some of the U.S.’s top insurance companies, including Cigna, Aetna, and UnitedHealthcare. Some insurers did catch on, and they even sent letters letting the man know they knew he was not a doctor and was committing healthcare fraud, but they didn’t stop paying his claims.

The fraudster’s ex-wife and her father even reported the fraud to insurers and regulators. That didn’t mean the insurers or regulators stepped in to stop the fraud.

The insurers told ProPublica that they just assume people are being honest when they submit claims. Moreover, the Texas man kept using different organization names and tax ID numbers, which made it harder to catch him. Ultimately, the man was convicted of federal health care fraud.

Now, a bipartisan group of U.S. senators has proposed the Medical License Verification Act, which would require Medicare & Medicaid Services to verify that NPI applicants have valid licenses in good standing before an NPI could be issued.

The bill will now head into committee, where co-sponsor Rick Scott (R-Fla.) says it will be considered.

The bill, if passed, will create an extra step for providers before they can begin billing insurers, but it might be worth the effort if it can stop frauds by people who obtain NPIs without licenses.