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Lawmakers Want Organizations With History of Fraud Out of ACO REACH

Analysis  |  By Jay Asser  
   December 14, 2022

Multiple payers are the target of concern in a letter to CMS urging for an investigation into program participants.

A group of House and Senate Democrats are asking CMS to boot organizations that have committed fraud out of the ACO REACH program before they "further encroach on the Medicare system."

In a letter to CMS administrator Chiquita Brooks-LaSure, the lawmakers, led by Senator Elizabeth Warren (D-Mass.) and Representative Pramila Jayapal (D-Wash.), express their concern that payers will continue "ripping off taxpayers" with their participation in the new payment model, which will start on January 1, 2023.

The ACO REACH program is replacing the Global and Professional Direct Contracting (GPDC) model, with participants of GDPC allowed to enroll as ACOs if they maintain a strong compliance record and agree to meet the requirement of the model. However, the lawmakers point out that participants have troubling records, including notable health insurers Centene, Humana, Cigna, Clover Health, and Bright Health.

A preliminary review of the direct contracting entities (DCEs) by Physicians for a National health Program (PNHP) found that at least 10 current GPDC participants had documented cases of fraud and abuse.
Centene, for example, paid $97 million in 2021 to settle allegations of "duplicated and inflated claims" to the Department of Veterans Affairs. The payer giant's pharmacy benefit managers also allegedly overcharged state Medicaid programs on prescription drugs last year, resulting in settlements that totaled more than $260 million.

"The ability of organizations with known histories of fraud and abuse to take part in the program increases the risks for Medicare beneficiaries, and raises concerns that CMS screening procedures for participants are inadequate, putting taxpayer dollars at risk" the lawmakers write.

The letter calls on CMS to address these issues and protect patients before the ACO REACH program begins by stopping the participation of the organizations with histories of fraud and removing DCEs that do not meet the new standards for the program.

In addition, the lawmakers want written answers to multiple questions by January 16, 2023, such as how organizations that have been accepted into GPDC been screened for acceptance into ACO REACH, and what methods CMS will use to screen ACO REACH participants.

Jay Asser is the contributing editor for strategy at HealthLeaders. 


Lawmakers are pressing CMS to examine participants in the new ACO REACH program that have histories of fraud and abuse.

Health insurers like Centene, Humana, Cigna, Clover Health, and Bright Health are under scrutiny for their concerning records.

The letter asks for action and to answer questions related to the screening process for ACO REACH participants.

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