[Senate Hearing 114-859]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 114-859

                    THE DOCTOR IS NOT IN: COMBATING
                   MEDICARE PROVIDER ENROLLMENT FRAUD

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS


                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             JULY 22, 2015

                               __________

                           Serial No. 114-10

         Printed for the use of the Special Committee on Aging
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         


        Available via the World Wide Web: http://www.govinfo.gov
        
                               __________
 
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
48-875                      WASHINGTON : 2022                     
          
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                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 CLAIRE McCASKILL, Missouri
MARK KIRK, Illinois                  BILL NELSON, Florida
JEFF FLAKE, Arizona                  ROBERT P. CASEY, JR., Pennsylvania
TIM SCOTT, South Carolina            SHELDON WHITEHOUSE, Rhode Island
BOB CORKER, Tennessee                KIRSTEN E. GILLIBRAND, New York
DEAN HELLER, Nevada                  RICHARD BLUMENTHAL, Connecticut
TOM COTTON, Arkansas                 JOE DONNELLY, Indiana
DAVID PERDUE, Georgia                ELIZABETH WARREN, Massachusetts
THOM TILLIS, North Carolina          TIM KAINE, Virginia
BEN SASSE, Nebraska
                              
                              ----------                              
              
              Priscilla Hanley, Majority Staff Director
                 Derron Parks, Minority Staff Director
                         
                         
                         C  O  N  T  E  N  T  S

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                                                                   Page

Opening Statement of Senator Susan M. Collins, Chairman..........     1
Opening Statement of Senator Claire McCaskill, Ranking Member....     2

                           PANEL OF WITNESSES

Seto J. Bagdoyan, Director, Audit Services, Government 
  Accountability Office, Washington, D.C.........................     5
Shantanu Agrawal, M.D., Deputy Administrator, Centers for 
  Medicare and Medicaid Services (CMS), and Director, Center for 
  Program Integrity (CPI), Washington, D.C.......................     6
Katherine M. Leff, R.N., Director, Special Investigations Unit, 
  Care Source Management Group, Dayton, Ohio.....................     8

                                APPENDIX
                      Prepared Witness Statements

Seto J. Bagdoyan, Director, Audit Services, Government 
  Accountability Office, Washington, D.C.........................    41
Shantanu Agrawal, M.D., Deputy Administrator, Centers for 
  Medicare and Medicaid Services (CMS), and Director, Center for 
  Program Integrity (CPI), Washington, D.C.......................    57
Katherine M. Leff, R.N., Director, Special Investigations Unit, 
  Care Source Management Group, Dayton, Ohio.....................    67

                        Questions for the Record

Seto J. Bagdoyan, Director, Audit Services, Government 
  Accountability Office, Washington, D.C.........................    73
Shantanu Agrawal, M.D., Deputy Administrator, Centers for 
  Medicare and Medicaid Services (CMS), and Director, Center for 
  Program Integrity (CPI), Washington, D.C.......................    75

                       Statements for the Record

GAO Report - Medicare Program....................................    79

 
                    THE DOCTOR IS NOT IN: COMBATING
                   MEDICARE PROVIDER ENROLLMENT FRAUD

                              ----------                              


                        WEDNESDAY, JULY 22, 2015

                                       U.S. Senate,
                                Special Committee on Again,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:17 p.m., Room 
562, Dirksen Senate Office Building, Hon. Susan M. Collins, 
Chairman of the Committee, presiding.
    Present: Senators Collins, Cotton, Tillis, Sasse, 
McCaskill, Casey, Whitehouse, Donnelly, Warren, Kaine.
    Also present: Senator Carper.

                 OPENING STATEMENT OF SENATOR 
                   SUSAN M. COLLINS, CHAIRMAN

    The Chairman. The Committee will come to order. Good 
afternoon. Before I begin my remarks, let me thank our Ranking 
Member, Senator Claire McCaskill, for proposing this hearing on 
improper payments in the Medicare program. This is an 
incredibly important topic to which Senator McCaskill has 
supplied her formidable investigative skills.
    Today we will examine the GAO's latest assessment of 
efforts to prevent these improper payments which are now 
estimated at an astonishing $60 billion, or nearly 11 percent 
of Medicare's total spending. This problem calls to mind the 
old adage, the more things change, the more they remain the 
same, for it was in 1998 when I was Chairman of the Permanent 
Subcommittee on Investigations that I held a series of hearings 
to examine fraud in the Medicare program.
    Those hearings uncovered dramatic examples such as the 
payments of $117,000 to two so-called physicians whose address 
was actually a laundromat in Brooklyn. We also found $6 million 
paid to durable medical equipment companies that supposedly 
were headquartered in the middle of a runway at the Miami 
International Airport.
    We were able to cull PSI's archives to find photos of these 
provider locations which you can see on the monitors. Seventeen 
years later, after I chaired these hearings, I am dismayed to 
learn that improper payments are still flowing to con artists 
who billed the system from fictitious locations.
    Take a look at the provider locations highlighted by the 
GAO in the report that is released today. One turns out to be a 
burger joint. Another, a vacant lot. They say a picture is 
worth a thousand words. These pictures, side-by-side, 
illustrate the ongoing risk of improper payments in the 
Medicare system and the billions of taxpayer dollars that are 
already lost.
    Since 1990, the GAO has identified Medicare as being at 
high risk for improper payments and fraud. The central question 
for us to ask today is why, after so many years, does Medicare 
remain unable to distinguish between legitimate healthcare 
providers seeking payment for services rendered and con artists 
looking to scam the system.
    In part, the answer is that the task of ferreting out 
wasteful and fraudulent spending is made all that much more 
difficult by the ingenuity of scam artists, but it is also true 
that Medicare has dismally failed to take the comprehensive 
actions needed to seal its systems against vulnerabilities.
    For example, the software used by Medicare to check 
provider addresses does not flag invalid locations such as UPS 
stores, mailboxes, or vacant lots, or burger joints, for that 
matter. Just checking these addresses using websites like 
Google Maps or 411.com would be an easy way to spot invalid 
addresses. Yet, inexplicably, CMS issued guidance in March of 
last year discouraging this simple practice.
    Likewise, the procedures used by Medicare to screen 
providers remain inadequate. While they are an improvement over 
past practice, they ought to be strengthened. It is clear that 
we must do more to shift from a pay-and-chase strategy to 
combat Medicare fraud to one that prevents the harm from ever 
occurring in the first place.
    Our witnesses have a wealth of knowledge about Medicare's 
fraud prevention mechanisms and what can be learned from 
private insurers and other stakeholders to reduce improper 
payments. I look forward to their testimony and hope that 17 
years from now we are not complaining about the failure of 
Medicare to implement simple fraud protection procedures. It is 
now my pleasure to turn the hearing over to Senator McCaskill 
for her opening statement, introductions of witnesses, and the 
first round of questions.

                 OPENING STATEMENT OF SENATOR 
                CLAIRE McCASKILL, RANKING MEMBER

    Senator McCaskill. Thank you so much, Chairman Collins. 
Before I get started, I do want to acknowledge on the record 
our colleague, Senator Carper, for his dedication to this 
issue. The GAO report was requested jointly by a number of us 
including him and we have worked together a long time on 
improper payments and improving and safeguarding the Medicare 
program. I know that Senator Collins has also worked with him 
when she previously served on the Homeland Security and 
Government Affairs Committee.
    The Medicare program is an essential commitment that we as 
a society have made to Americans in their golden years. Through 
Medicare, our Government provides high quality medical care to 
seniors at an affordable cost for as long as they need it. We 
owe it to seniors and taxpayers to do our best to eliminate any 
potential fraud in the program so seniors can receive the best 
care and taxpayer dollars are not wasted.
    Unfortunately, it appears that the Centers for Medicare and 
Medicaid Services, known as CMS, is falling down on some key 
aspects of ensuring that it is successfully implementing the 
very first step in eliminating fraud, preventing illegitimate 
providers from enrolling in the program. Before a provider can 
be reimbursed for taking care of beneficiaries, he or she must 
be enrolled in the program. CMS relies on contractors to handle 
and verify these enrollments.
    The enrollment process is intended to ensure that the 
healthcare providers and suppliers in Medicare are licensed and 
legitimate providers of healthcare services. This is a 
relatively straightforward process that has four main steps. 
First, verifying an actual practice location for the provider; 
second, verifying that the licensure information listed in the 
application is accurate; third, verifying that the providers 
are not deceased; and fourth, verifying that providers had not 
previously been excluded from doing business with the Federal 
Government.
    We asked GAO to review whether CMS was accomplishing these 
four steps. Although GAO found no major problems in CMS's 
process for ensuring the providers it enrolls in Medicare are 
alive and not excluded from working with the Federal 
Government, it found that CMS had some pretty big blind spots 
on the other two verification points.
    First, as the illustrations today clearly show, CMS is 
doing a poor job of flagging potentially ineligible practice 
locations. This includes enrolling providers who list their 
practice addresses as rented mailboxes from companies like UPS 
and Mailboxes, Etc., and enrolling those who list their 
practice addresses at fast food restaurants or even vacant 
lots.
    Although GAO did not have access to detailed enough claims 
information to be able to figure out exactly how much CMS paid 
out to ineligible providers, the total amount is in the 
hundreds of millions, perhaps as big as $1 billion. I 
understand that CMS does not have the resources to require its 
contractors to conduct in-person visits to all 1.8 million 
Medicare providers and suppliers, but it is inexcusable for 
CMS, especially in light of today's technology, to not have the 
built-in ability to flag potentially invalid, vacant, or rented 
mailbox addresses when the United States Postal Service flags 
such addresses and provides that information to CMS. This 
should be easy, and yet, CMS has potentially misspent billions 
of dollars throughout the years because it failed to use this 
readily available information. During today's hearing, I plan 
to examine exactly why this has been the case for so long and 
how the Government can better contract for services that 
actually utilize the information it needs to prevent fraud.
    GAO also found that CMS's process for checking adverse 
actions on physicians' licenses before enrolling them in 
Medicare is woefully lacking. CMS currently relies on 
physicians to self-report any adverse action on licenses that 
he or she may have in states other than where he or she is 
enrolling in Medicare.
    Now, if a physician is enrolling to be a Medicare provider 
in Missouri with a clean Missouri medical license and a revoked 
Illinois medical license, that revoked Illinois medical license 
is something that CMS should know about. It is certainly 
something I would want to know about, and although CMS may have 
felt confident in relying on such a physician to self-report 
that revoked license, I believe that both seniors and taxpayers 
deserve much more protection and vigilance from CMS against 
unscrupulous physicians. Relying on self-reporting cannot 
provide the necessary protection.
    I have questions today about why CMS has structured its 
licensure check to rely on self-reporting and I plan to dig 
deep into CMS's current plans for fixing this problem. Next 
week is the 50th anniversary of the Medicare program. For 50 
years, it has protected the health and well-being of millions 
of seniors including the 50 million or so currently enrolled in 
Medicare. This is a stunning achievement by our Government. I 
want to acknowledge and applaud that achievement.
    Today's hearing is not about tearing the program down. It 
is about how we can all work together to make it better and 
ensure that it continues to provide quality care for our 
seniors, living up to the commitment our Government has made to 
them in their golden years. I thank the witnesses for being 
here today. First, we have Dr. Shantanu Agrawal--close?
    Dr. Agrawal. Close. It is Shantanu.
    Senator McCaskill. Shantanu?
    Dr. Agrawal. Yep.
    Senator McCaskill. Agrawal.
    Dr. Agrawal. Agarwal.
    Senator McCaskill. Agarwal?
    Dr. Agrawal. I am good with that.
    Senator McCaskill. Okay. I am sorry. I am sure you have 
this every day, right? You are used to it.
    Dr. Agrawal. More often than not, yes.
    Senator McCaskill. More often than not. He is the Deputy 
Administrator of the Centers for Medicare and Medicaid and the 
Director of the Center for Program Integrity. He comes to this 
position having served as chief medical officer of CPI. He is a 
board-certified emergency medicine physician and fellow of the 
American Academy of Emergency Medicine.
    Mr. Seto Bagdoyan--you guys are killing me today--is the 
Director of Audit Services at the Government Accountability 
Office. During his GAO career, Mr. Bagdoyan has served in a 
variety of positions including as legislative advisor in the 
Office of congressional Relations and as an Assistant Director 
for Homeland Security and Justice. He has also served on 
congressional details with the Senate Finance Committee and the 
House Committee on Homeland Security.
    Finally, Katherine M. Leff--this is very nice--who is a 
registered nurse, is the Director of the Special Investigations 
Unit for CareSource Management Group. CareSource is a non-
profit managed healthcare plan headquartered in Dayton, Ohio. 
It offers managed healthcare plans including Medicaid plans, in 
Ohio, Kentucky, and Indiana. Ms. Leff is also the current Chair 
of the National Healthcare Anti-Fraud Association.
    We would ask that your oral testimony be no more than five 
minutes. Your written testimony will be printed in the record 
in its entirety. Thank you all and I look forward to hearing 
from you. Mr. Bagdoyan, we will begin with you.

                 STATEMENT OF SETO J. BAGDOYAN,

              DIRECTOR, AUDIT SERVICES, GOVERNMENT

            ACCOUNTABILITY OFFICE, WASHINGTON, D.C.

    Mr. Bagdoyan. Thank you. Chairman Collins, Ranking Member 
McCaskill, Senator Carper who has joined us, and members of the 
Committee, I am pleased to be here today to discuss the results 
of GAO's recent report on the Medicare eligibility verification 
process for providers and suppliers.
    As Chairman Collins mentioned earlier, Medicare is a 
significant expenditure for the Federal Government. In Fiscal 
Year 2014, Medicare paid $554 billion for healthcare and 
related services, of which CMS estimates that about $60 
billion, or 11 percent, were improper payments. This is an 
increase from the Fiscal Year 202013 level of about $49.9 
billion.
    Earlier this year we reported that Medicare remains on 
GAO's high-risk list partly because of continuing concerns 
about the adequacy of fiscal oversight of the program including 
improper payments. My remarks today highlight key findings from 
our review of four enrollment screening controls CMS uses to 
prevent and detect enrollment fraud involving its provider, 
enrollment chain, and ownership system, also known as PECOS.
    Based on our review, we found that controls used to screen 
for providers and suppliers listed as deceased or excluded from 
participating in Federal or healthcare related programs appear 
to be generally working. However, we identified weaknesses in 
two other controls. First, we identified weaknesses in CMS's 
verification of practice locations.
    Medicare providers must submit the address of the practice 
location from which they offer services. The software CMS uses 
to validate addresses does not flag potentially ineligible 
addresses such as rental mailboxes, and it also does not flag 
vacant or invalid addresses which are those where providers or 
suppliers no longer reside or those not recognized by the U.S. 
Postal Service.
    Of the 980,000 addresses in PECOS, we examined using Postal 
Service software. About 105,000 initially appeared as a CMRA, 
that is essentially a rental mailbox, a vacant address, or an 
invalid address. Based on subsequent analyses of a projectable 
sample of 496 addresses, we estimated that about 22 percent of 
the 105,000 addresses, or 23,400, are potentially ineligible.
    Separately, CMS's March 2014 guidance reduced address 
verification steps conducted by its contractors. CMS's 2013 
guidance encouraged contractors to conduct additional 
verification steps such as using Google Maps and conducting 
site visits. However, CMS's latest guidance does not reference 
such a steps beyond contacting the provider. By reducing 
verification steps, CMS has increased its vulnerability to 
potential fraud.
    We recommended CMS incorporate flags into its software to 
help identify questionable addresses and revise its 2014 
guidance to enhance verification of practice locations. CMS 
agreed with the first recommendation and disagreed with the 
second. We believe additional address verification steps to be 
an essential control and stand behind our recommendation.
    Second, we identified weaknesses in the verification of 
medical licenses. Medicare physicians are required to hold an 
active license in the State they practice in and report any 
final adverse actions to CMS. Final adverse actions include 
license suspensions or revocations by any State licensing 
authority.
    We found 147 out of the approximately 1.3 million 
physicians listed as eligible in PECOS had received a final 
adverse action and were either not revoked from PECOS or 
revoked at a much later time.
    In March 2014, CMS began providing a report to its 
contractors to improve licensure reviews. While a good first 
step, this report only includes current licensure status for 
the State in which providers enroll. It does not include the 
full adverse action history of these licenses or their licenses 
in other states, creating the opportunity for ineligible 
physicians to enroll into PECOS. We recommended CMS collect 
additional licensure information to ensure providers are self-
reporting all final adverse actions and CMS agreed with this 
recommendation.
    In closing, our findings highlight that CMS needs to 
maximize its efforts to promote program integrity to ensure 
ineligible or fraudulent providers and suppliers do not enroll 
into PECOS. Our recommendations in this regard are designed to 
enhance CMS's toolbox and help narrow the window of opportunity 
for potential improper payments and fraud. Madam Chairman, this 
concludes my statement. I look forward to the Committee's 
questions.
    Senator McCaskill. Thank you.
    Dr. Agrawal.

          STATEMENT OF SHANTANU AGRAWAL, M.D., DEPUTY

            ADMINISTRATOR, CENTERS FOR MEDICARE AND

         MEDICAID SERVICES (CMS), AND DIRECTOR, CENTER

         FOR PROGRAM INTEGRITY (CPI), WASHINGTON, D.C.

    Dr. Agrawal. Thank you. Chairman Collins, Ranking Member 
McCaskill, Senator Carper and members of the Committee, thank 
you for the invitation to discuss CMS's work to improve 
provider and supplier enrollment systems. Enhancing program 
integrity is a top priority for the Administration and an 
agency-wide effort at CMS.
    Thanks in part to the authorities provided by the 
Affordable Care Act, CMS has improved the provider and supplier 
enrollment and screening process. We are seeing real results 
from our efforts and have generated over $927 million in 
savings from just our enrollment and screening work in the last 
four years.
    These actions are part of a larger set of provider 
enrollment activities which have saved the program $2.4 billion 
in avoided costs. These savings reflect the actions CMS has 
taken to deactivate billing privileges for more than 540,000 
providers and suppliers that do not meet Medicare requirements 
and to revoke the enrollment and billing privileges of an 
additional 34,000 providers and suppliers.
    As required by the ACA, and in line with broader changes in 
program integrity, CMS has implemented risk-based screening of 
providers and suppliers who want to participate in Medicare and 
Medicaid which require certain categories of providers and 
suppliers that have historically posed a higher risk of fraud 
to undergo greater scrutiny prior to their enrollment or 
revalidation.
    Providers in the limited risk category undergo verification 
of licensure and compliance with Federal regulations and State 
requirements, frequently in an automated manner. Providers and 
suppliers in the moderate and high risk categories undergo 
additional screening including fingerprint-based background 
checks, criminal record searches, and unannounced site visits.
    CMS uses site visits to verify that a provider or 
supplier's practice location meets requirements and helps 
prevent questionable providers and suppliers from enrolling in 
the Medicare program. Since 2011, CMS has completed 220,000 
site visits which have resulted in nearly 1,300 revocations. 
Importantly, these activities have also stopped nearly 5,000 
initial enrollments in the last 12 months which means the 
provider was not able to enroll or enter the Medicare program.
    Today's GAO report confirms that our risk-based approach to 
enrollment is effective, particularly in addressing higher risk 
providers. It also shows that we could do more to scrutinize 
certain limited risk providers like physician practices. We 
appreciate the GAO's recommendations and will take several 
steps to address these recommendations.
    To better target limited risk providers, CMS has begun 
conducting ad hoc site visits to these providers to further 
ensure that every provider entering the Medicare program meets 
program requirements and are valid and operational. CMS already 
uses USPS data in our address verification system, and to 
strengthen the enrollment screening process, CMS will enhance 
the address verification software to better detect potentially 
ineligible addresses in line with GAO's recommendation.
    We are working toward configuring the provider and supplier 
address verification system in PECOS to flag commercial mail 
receiving agencies, vacancies, invalid addresses, and other 
potentially questionable practice locations. We expect this 
enhancement to be complete by early next year.
    In their report, GAO sampled 496 Medicare locations as a 
sample of the enrollment data. GAO referred 92 locations with 
the most concerning questionable addresses to CMS for further 
investigation and appropriate action, as this figure shows. The 
vast majority of these locations were found to be operational, 
contained clerical keying errors, and otherwise legitimate 
providers, or were already previously revoked or deactivated 
through our ongoing efforts.
    Importantly, not a single high risk provider in the GAO 
sample had fallen through the cracks. Some addresses were 
locations of legitimate, limited risk providers with other 
addresses on file, the provider moved without closing out a 
previous address in our system.
    In fact, I would point out that the two examples brought up 
by Chairman Collins were both examples of locations of limited 
risk physicians practices that in fact had moved and had not 
billed the program in over a decade. In all, this accounted for 
80 of the locations out of 92 and only 12 of the locations 
referred by the GAO required CMS to take an administrative 
action.
    Even among this set, eight of these twelve locations did 
not bill the Medicare program during the time period studied by 
GAO. Based on GAO's own methodology, this administrative action 
rate is only .3 percent of all addresses in PECOS. It is 
important to note that these twelve locations were all of 
limited risk providers, suggesting that our risk-based approach 
to targeting our program integrity efforts to higher risk, high 
dollar providers has been effective.
    GAO's report has helped us to better understand where our 
efforts are succeeding and where we have further work to do. 
Their work will help inform our efforts going forward to focus 
on certain limited risk providers which will be driven by data 
analysis and other lead generation approaches. As I stated 
earlier, CMS is committed to strengthening provider and 
supplier enrollment and screening processes to make sure that 
Medicare beneficiaries receive items and services from 
appropriate providers and taxpayer dollars are protected, but 
the importance of program integrity efforts extends beyond 
dollars in healthcare costs alone. It is fundamentally about 
protecting our beneficiaries and ensuring we have the resources 
to provide for their care. We are committed to working with GAO 
as we continue to strengthen program integrity. We look forward 
to working with this Committee and Congress on these efforts. 
Thank you.
    Senator McCaskill. Thank you, Doctor.
    Ms. Leff.

        STATEMENT OF KATHERINE M. LEFF, R.N., DIRECTOR,

            SPECIAL INVESTIGATIONS UNIT, CARE SOURCE

                 MANAGEMENT GROUP, DAYTON, OHIO

    Ms. Leff. I want to thank Chairman Collins, Ranking Member 
McCaskill, and Senator Carper and the distinguished members of 
the Special Committee on Aging for the opportunity so speak to 
you today about the GAO report calling for improved eligibility 
verification of providers and suppliers.
    CareSource agrees with the GAO report recommendations. 
However, we also recognize the challenges CMS faces in 
identifying fraudulent providers in the enrollment process due 
to CMS's enormous size and any willing provider requirement. 
Private plans are much smaller, have more control over 
providers entering into and staying in our network.
    The GAO report identified two weaknesses in Medicare 
provider enrollment screening, the verification of provider 
practice locations and physicians' licensure status. In my 
testimony, I offer CareSource's process as a means of 
comparison for the Committee. At CareSource, we do the 
following to verify practice locations and licensure status.
    First, we require a Council on Affordable Healthcare 
Quality Healthcare credentialing application. We obtain then a 
report from the National Practitioner Data Bank which provides 
licensure, practice address, malpractice cases, and any adverse 
actions. We conduct secret shopper calls to provider offices. 
We utilize a USPS address verification software to identify 
invalid addresses.
    However, it is important to note here that providers have 
multiple addresses. One of those addresses may be a P.O. box at 
a UPS store that is used to secure payment, provide access for 
mailing for payment by the provider or the providers' billing 
company. We also do periodic onsite visits at providers' 
offices. We obtain the providers' malpractice insurance 
certificate. We pull providers' AMA physician profile. We check 
license boards in all states.
    We also enter the providers into a software program that 
checks the providers against State licensing boards, the 
specially designated nationals list, Social Security Death 
Index, excluded parties list system, HHS OIG exclusions, and 
State provider sanctions list.
    It is important to note here that while this process is 
automated, mitigating the findings are not. Naming conventions 
in all these data bases are frequently different and there is 
not enough information to confirm matches. Matches must be 
validated manually, which is a very resource intensive process.
    While we cannot always identify fraud in the enrollment 
process, many plans have methods in place to identify aberrant 
provider billing behavior. At CareSource, our Special 
Investigations Unit uses a rules-based post-payment fraud 
detection software to identify known fraud schemes. We are 
right now in the process of implementing a new fraud detection 
software that uses mathematically based predictive analytics. 
This new software also provides the opportunity to identify 
fraud prior to payment.
    We share identified fraud schemes and providers under 
investigations at fraud information sharing meetings, with law 
enforcement, Government agencies, and other plans. We report 
new fraud schemes in provider investigations to SIRIS, which is 
a national fraud data base through the National Healthcare 
Antifraud Association. We review grievance data looking for 
trends.
    We compare our providers' recredentialing to our 
investigative case tracking system to identify providers with 
issues. We send explanation of benefit forms to members to 
identify services not provided. CareSource's Special 
Investigation Unit works closely with internal CareSource 
departments and Federal and State agencies to proactively and 
cooperatively prevent and detect fraud, waste and abuse.
    Each year we enhance our prevention detection and 
investigative efforts by adding staff, software, and process, 
resulting in increased savings and member safety. Already in 
2015, we have taken significant actions on DME and allergy--
allergy cases, genetic labs, optical cases that have saved 
considerable taxpayer dollars. In addition, we have identified 
complicated issues in the home healthcare arena and are working 
collaboratively with State agencies and other plans to address 
these issues.
    Finally, in 2015, we saw the end results of a multiyear 
provider investigation by witnessing the provider being 
sentenced to six and a half years in prison for behavior that 
involved excessive CT scans, excessive knee and perciformis 
injections out of the country, drug purchases, et cetera.
    Thank you again for the opportunity to appear before you 
today to discuss the ways to prevent healthcare fraud. I would 
be pleased to address any questions you have.
    Senator McCaskill. Thank you. Thank you all for your 
testimony. Dr. Agrawal, let us start with an acknowledgment 
that the main way we have gone after fraud in the Medicare 
program is to pay and Chase, correct?
    Dr. Agrawal. I think that has been historically true, but 
in the last five years, we have changed significantly to a much 
more preventive footing.
    Senator McCaskill. Okay. The contractor that you use now, 
Finalist, is only able to standardize addresses, which I 
understand is like correcting misspellings and making sure they 
are correct. It is currently unable to flag rented mailboxes, 
vacant addresses, and invalid addresses, correct?
    Dr. Agrawal. The finalist software is used by our 
contractor. It has a couple of different data inputs including 
a USPS data base. It does have shortcomings compared to the 
data base that GAO has described, which is why we are also 
incorporating that level of data.
    Senator McCaskill. Okay. If it does not have the correct 
data that it needed, I assume that the employees, the 
contractor employees, could have gone to USPS and checked their 
website, right, for this data? I mean, what I am trying to 
figure out is, why in the world would we ever hire a contractor 
that was not doing a basic check that is available for free?
    Dr. Agrawal. I think we should maybe differentiate a little 
bit, Senator. We have Medicare administrative contractors that 
actually do the enrollment work.
    Senator McCaskill. Right.
    Dr. Agrawal. We have program integrity contractors that 
supply them with tools, resources, technologies, data bases to 
do that.
    Senator McCaskill. Well, but do we really need somebody to 
supply them with a basic that you can check USPS for free to 
see if it is a valid address? We need another layer to do that?
    Dr. Agrawal. Well, what we have been moving toward in order 
to really have that position toward prevention is automated 
approaches through these kinds of checks. We have been 
implementing over several years now and working to improve, the 
automated provider screening system. One of the things that 
that system does is look at address verification. It also looks 
for licensure, and now, most recently, we have been working to 
incorporate criminal background history into that system. Our 
approach is to try to give our enrollment contractors as much 
consistent automated, timely, actionable data that we possibly 
can.
    Senator McCaskill. How much are we paying to Finalist for 
address checks that we can do for free through USPS--through 
the Postal Service?
    Dr. Agrawal. Again, we pay--so I do not have a specific 
number in front of me, Senator. I am happy to get that for you.
    Senator McCaskill. Should you not know that coming to this 
hearing, what we pay them?
    Dr. Agrawal. Well, what we do is we bring on board various 
data bases, so we have over 100 data bases that perform the 
kind of enrollment checks that we need. All of that is filtered 
through the automated provider screening system utilizing 
physician identifiers, other information like that, and made 
available, so what we have is, we have costs associated with 
rolling on those data bases and relatively few, we hope, for 
individual manual checks. I mean, the whole purpose is to move 
away from manual checks that might be inconsistent to totally 
consistent automated checks.
    Senator McCaskill. I know you understand the point I am 
making.
    Dr. Agrawal. Sure.
    Senator McCaskill. That this information, and I think the 
point was made very clearly in this audit, it is a good audit, 
and it points out that the basic address checks that can be 
done through technology very simply and for free were not being 
done by the paid contractor that was supposed to be doing 
address checks, correct?
    Dr. Agrawal. Senator, I agree that this report is useful.
    Senator McCaskill. That is good.
    Dr. Agrawal. It definitely has highlighted areas of 
improvement for us. I think what the report also highlights is 
that there is no such thing as a perfect single data base. What 
we saw in the sample, as I discussed in my opening remarks, and 
the sample provided to us by GAO, is that several addresses 
were actually legitimate, several were truly operational at the 
address identified for us by GAO, and indeed some really did 
need administrative action.
    Senator McCaskill. Well, I am a little troubled, honestly, 
with the chart.
    Dr. Agrawal. Okay.
    Senator McCaskill. Let me tell you why. There are two ways 
to take an audit. One way is to say, you know, this is a good 
point. We can do better. This is basic information that is 
available with a few clicks, free from the United States Postal 
Service, and we have got to get this integrated as quickly as 
possible, and by the way--and I will save these questions for 
later because I will not have time on this round--about this 
contractor. Why in the world we have a contractor that did not 
integrate this into their software check is beyond me since 
this is a fairly important part of a--it is a four-step process 
and this is one of the steps, so your chart, GAO referred you a 
list of 92 providers, correct?
    Dr. Agrawal. Correct.
    Senator McCaskill. That list of 92 providers was determined 
from a generalized sample of 496 providers, correct?
    Dr. Agrawal. Correct.
    Senator McCaskill. That generalized sample of 496 
represents .47 percent of the potentially ineligible addresses, 
correct?
    Dr. Agrawal. The number I will take as given from you.
    Senator McCaskill. Well, Mr. Bagdoyan will check my math, 
but I believe my math is correct, so your chart shows that four 
of these addresses required administrative action, had billing 
activity. How much did you indicate was paid to those four 
providers, how much money?
    Dr. Agrawal. I will have to check on that again.
    Senator McCaskill. I know. It was $1.2 million from 2005 to 
2013. You should know. Since GAO used a generalized sample, we 
can statistically assume that roughly what applies to those 496 
will apply to the whole group of 105,000, correct?
    Dr. Agrawal. I would have to defer on methodology to the 
GAO.
    Senator McCaskill. Correct, Mr. Bagdoyan?
    Mr. Bagdoyan. That is correct, Senator.
    Senator McCaskill. Okay, so relying on that statistical 
projection, if we were able to say that for each group of 496 
ineligible, there would be about $1.2 million paid out 
fraudulently and we apply it to the entire group, we come up 
with $254 million.
    Now, you coming in here and showing us a chart that there 
is only four I think is completely misleading and worries me 
that you are not saying, you know, we had a problem and we are 
going to get after it and fix it. What you have done instead is 
created a chart that we got a half hour before the hearing that 
skews the data and makes it look like you only had four 
addresses out of the hundreds of thousands that were identified 
by GAO, which is completely misleading.
    Dr. Agrawal. Senator, the GAO was most concerned and asked 
us to investigate, look into the 92 cases that they had 
presented to us. They presented that data, you know, with the 
expectation that most of those addresses would be concerning. 
We tracked them down with diligence performing the necessary 
subsequent investigative actions that included site visits, 
other kinds of data analytics.
    We wanted to be forthcoming with both the GAO that has 
asked the data from us, and this Committee, about our findings. 
Now, none of that suggests that the GAO's recommendations are 
not legitimate or that there are not improvements that we ought 
to make. In fact, I believe I stated that up front in my 
remarks and I am happy to state it again.
    I believe that they have found a tool that will enhance our 
efforts. We are working to incorporate that tool into our 
screening systems. I did not want to leave you with the 
impression that somehow all 92 of these locations were truly 
fraudulent billers because I think that does not reflect the 
reality on the ground.
    Senator McCaskill. Well, I appreciate that. I think you can 
also appreciate that it looks a little bit like circling the 
wagons and gosh, this really is not that big a problem, and I 
think we do have a problem when something as simple as checking 
addresses is not being done by the contractor. Thank you. I 
have gone two minutes over and my colleagues have been very 
patient. Madam Chairman.
    The Chairman. Thank you very much. I am glad that you went 
over it because I share your concern and outrage over this 
issue. I want to switch to a different issue and that is the 
physicians with active provider numbers were collecting money 
and yet, have an adverse action from a State Medical Board that 
resulted in a suspension or revocation of their license.
    First I will start with you, Mr. Bagdoyan. GAO's review 
found that 321 physicians with active provider numbers had 
received an adverse action from their State Medical Board, and 
we are talking about serious adverse actions. I am going to 
have the chart put up so that everyone sees. It is a little 
hard to read, at least for my eyes, but I think this will make 
the point.
    Can you tell me how the GAO determined that these 
physicians' licenses had been revoked or suspended and why CMS, 
by contrast, still considered them to be active providers 
eligible for Medicare payments?
    Mr. Bagdoyan. Thank you for your question. What we did was 
we used the Federation of State Medical Boards' data base of 
licensure which has the most complete history of licensure as 
well as adverse actions for all licenses for a particular 
physician. We also researched the individual State data bases 
as well as referred to the PECOS data base as well.
    The Chairman. Is there any reason why CMS could not refer 
to those same data bases?
    Mr. Bagdoyan. I would have to refer that question to Dr. 
Agarwal for a response.
    The Chairman. I spent five years in State government and 
part of my job was reviewing licensing and I know our State 
board of medicine always did a check of other states before 
granting a license in Maine. That was just due diligence on 
their part, so this is of great concern to me. Doctor, on April 
29th, the GAO referred 147 providers to CMS whom GAO had 
identified as having had an adverse action resulting in 
suspension or revocation of one of their medical licenses, and 
yet, they have not been removed from the Medicare program or 
they remained an eligible biller for months after that adverse 
action against their license.
    Now, just so everyone understands in case not everybody can 
read this chart, I want to emphasize how egregious the referred 
cases are. For example, out of the 78 adverse license actions 
GAO identified for sexual misconduct, 48 of those providers, or 
61 percent, were either not revoked from the Medicare program 
until months after the adverse action or never removed. How can 
this happen? Why does not CMS use the same data bases that GAO 
did?
    Dr. Agrawal. Why do I not start there, Senator. What we 
have done in order to get licensure information is try to go 
back to the source, so as I mentioned just a few minutes ago, 
we have rolled in over 100 data bases specifically on 
licensure, not relying on a single source of that data, by 
trying to get actually back to states and try to get that data, 
you know, from as much of the source as possible so that it is 
timely and accurate, because licensure information can actually 
change quite a bit even for, you know, valid physicians.
    I think to your broader point, Senator, there is absolutely 
no way that I defend the presence of a criminal or a convict, a 
felon in the Medicare program. I think it is clearly our job, 
when those cases are identified either proactively by us or 
even in responses to report by GAO or others, to react swiftly.
    Now, GAO did give us, to your point, 147 leads to 
investigate which were concerning from their perspective for 
licensure issues. I am happy to share the results with them. I 
want to be careful when I do that, I am not sending the message 
that we have not taken their recommendations seriously. We 
still do, but I am happy to share the results on the ground in 
terms of what we found with these 147 cases.
    The Chairman. Well, GAO asked for a response from you by 
June 29th. Has that response occurred?
    Dr. Agrawal. I do not believe we have formally sent it to 
them in writing yet. We will obviously be doing that. We have 
been working diligently on looking at each and every one of 
these cases, trying to get underneath the potential licensure 
issues. What we have generally found is there were 19 
revocations for licensure issues that we were able to take out 
of the 147, so we are grateful to the GAO for those leads.
    The remainder of the cases, which we will obviously be 
sharing, were cases where we had already taken an action like a 
revocation or deactivation, or where we could not corroborate 
the licensure issue, or the licensure issue would not have been 
a disqualifying event in Medicare.
    The Chairman. Well, Doctor, I can tell you that I know from 
talking to GAO that CMS has not responded, and so you are 
overdue with your response.
    Dr. Agrawal. Correct.
    The Chairman. To me, if I were in your position and GAO, 
which has done all this work for you, gave you this list, I 
would be really concerned that you have individuals with 
revocation of their license who are still receiving Medicare 
payments or at least are eligible for those payments, 
especially when GAO was able to identify them from just going 
to a consolidated data base. Thank you.
    Senator McCaskill. Thank you.
    Senator Kaine.
    Senator Kaine. Thank you to Madam Chair and Ranking Member 
and to our witnesses. Dr. Agarwal, you are getting the 
attention today, so I think I am going to stick with you for a 
second. Here is a fraud and abuse issue that I am very 
concerned about.
    Not this GAO study, but other recent reports have really 
focused upon the number of opioid prescriptions and fraud and 
abuse in the Medicare Part D program. A lot of challenges with 
opioids. We are seeing them all across the Nation. We are 
seeing them in the VA system. We are seeing them in the private 
pay. We are seeing them in Medicare. The studies have shown 
that the opioid prescriptions within Medicare Part D have 
increased dramatically higher than other drug prescriptions and 
there are some geographical hot spots in that.
    I hear about this all the time. In Virginia, it does not 
respect class or geography. It is a serious problem. Talk to us 
about CMS's efforts to try to control the fraud and abuse and 
especially with respect to opioid prescriptions in Medicare 
Part D.
    Dr. Agrawal. Senator, thank you. That is obviously a very 
important area and as a physician who has seen the ravages of 
substance abuse and other related issues, I completely agree 
that it is a priority. We have been doing more work in the Part 
D program to address beneficiary issues as well as provider 
issues, and then the various intermediaries, Part D plan 
sponsors as well as pharmacies.
    On the provider side, one of the biggest actions that we 
are working to implement over the next year is full enrollment 
of Part D prescribers. This hearing so far has focused on 
enrollment on the Medicare A-B side. We are implementing 
similar authorities and controls in Part D so that every 
prescription written in Part D is by a Medicare approved 
provider.
    That is a radically new stance in Medicare than has been 
adopted historically. That will allow non-qualified providers, 
really for Part D plan sponsors, to place edits in their system 
so that prescriptions from those providers simply cannot be 
filled. I think that will help really make sure that providers, 
again, are licensed to have DEA licensure and other things that 
are more germane to----
    Senator Kaine. This is not opioid-specific. This is general 
systemwide improvement to try to track, right?
    Dr. Agrawal. Correct. On the beneficiary side, we look at--
we have an over-utilization monitoring system that focuses on 
particular beneficiaries that are above what we would consider 
and what the CDC considers safe thresholds of opioid 
utilization.
    We share that information about specific beneficiaries with 
Part D plan sponsors and then they are able to take, you know, 
elevated steps like case management and other utilization-
related steps to address these over-utilizing beneficiaries.
    We have noted through that kind of data sharing that there 
is a 28 percent reduction in those high-utilizer beneficiaries, 
that they are brought back down under safer thresholds. There 
are other kinds of data sharing that we do with Part D plan 
sponsors. We provide them, on a quarterly basis, information 
about aberrant pharmacies, aberrant prescribers so that they 
are able to take their own investigative actions and 
administrative actions as relevant.
    We have a healthcare fraud prevention partnership which Ms. 
Leff is a part of that encourages exactly that kind of data 
exchange and encourages exactly that kind of administrative 
action since a number of elements of the Part D program are 
actually directly administered by the plan sponsors not CMS, so 
it is very important to work with them and through them.
    Senator Kaine. Just to put on the record some statistics, 
between 2006 and 2014, Medicare spending on opioids went up 
from $1.5 billion to $3.9 billion in that eight year period, 
and in some regions of the country, Alabama, Tennessee, 
Oklahoma, and Alaska, more than 40 percent of Medicare 
beneficiaries file at least one prescription that includes a 
narcotic. That is really staggering, so these anti-fraud 
measures in that particular area in Medicare Part D are 
appreciated.
    Let me ask you just one more question for any of the 
witnesses. This is a panel that does significant oversight. We 
are not a legislative panel. We do not initiate legislation, 
but we are very interested in it. You have oversight tools and 
we will stay on you about them. Are there legislative 
improvements that could be made, in any of your opinion, that 
would advance an anti-fraud agenda so that we could better deal 
with this problem? Are there other things that we ought to be 
doing?
    Ms. Leff. One thing that I would suggest, Senator Kaine, is 
that in the Medicaid side, we have lock-in programs for 
members, and so what happens is when we find them abusing 
controlled substances, doctor shopping to get those substances, 
we lock them into one pharmacy, one provider. That is very 
effective.
    Then we have case managers working with them to get them 
into the right level of care. If they need psych care and that 
sort of thing, we get them into those type of areas, making 
sure that they are compliant with the program. It seems to be 
very effective in the Medicaid side, but it is not something 
that is permitted under Medicare. That would certainly be an 
opportunity.
    Senator Kaine. Do you know if that is a regulatory matter 
or a legislative matter?
    Ms. Leff. I am not certain.
    Senator Kaine. Dr. Agarwal, do you know?
    Dr. Agrawal. It is a legislative matter. We agree that 
lock-in programs can be beneficial. They are utilized in 
Medicaid by the private sector. We do not currently have this. 
In fact, we are statutorily not permitted to do and it is part 
of the President's budget that we would be happy to work with 
this Committee around to get that kind of authority.
    Senator Kaine. Great. Thank you very much. Thank you, Madam 
Chair.
    Senator McCaskill. Senator Warren.
    Senator Warren. Thank you, Madam Chair. You know, when the 
little guys, doctors' offices or pharmacies are caught breaking 
the law, they sometimes get kicked out of the Medicare program, 
but the consequences for giant corporations are very different. 
Instead of kicking these big time bad actors out of the 
Medicare program or putting CEOs in jail, the Government 
settles with a fine and the company enters a corporate 
integrity agreement, basically a promise not to break the law 
again.
    I want to consider one for-profit hospital chain, Tenet 
Health. It is a $5.8 billion corporation. Now, back in 1994, 
Tenet paid a $379 million fine, suggesting some pretty serious 
activity here, for illegal kickbacks to doctors, and it signed 
one of these corporate integrity agreements.
    Then in 2006, Tenet got caught fraudulently billing 
Medicare and giving illegal kickbacks to doctors for which they 
paid a $900 million fine, suggesting some pretty significant 
activity here, and signed a new corporate integrity agreement. 
Then in 2012, Tenet admitted to breaking the law again, while 
under the 2006 corporate integrity agreement, and it paid a $42 
million fine, and then just a year later, Tenet got another $4 
million slap on the wrist for misconduct that occurred while 
they were under the corporate integrity agreement.
    If a big company can commit major fraud again and again and 
again, and each time they just pay a fine and promise to be 
good and move on, I am not sure what incentive there is for 
them to stop breaking the law. Dr. Agrawal, why is it that a 
company like Tenet--we know about lots of other examples--are 
allowed to settle allegations of fraud over and over with just 
a fine and a promise not to break the law again? When is it 
that you say enough is enough?
    Dr. Agrawal. Senator, thank you for the question. We are an 
administrative agency, as you know. We have a variety of 
authorities that allow us to review medical records, recover 
overpayments, deny enrollment, revoke enrollment. From our 
perspective, there is no such thing as too big to fail. There 
is no provider that we cannot medically review. In fact, some 
of the providers that you cited we have conducted medical 
reviews of and secured overpayments.
    We perform the same screening activities for those 
providers and we have revoked or kicked out of the program 
institutional providers, larger institutional providers. With 
respect to settlements and CIAs in particular, those are 
activities that we as an administrative agency do not engage 
in. Those are conducted by the DOJ and Office of Inspector 
General. I could not really address for you what their 
thresholds are for taking action beyond those.
    Senator Warren. Well, so fair enough that you do not speak 
for them, but you testified here last year and when you did, I 
asked you about how CMS, the HHS Inspector General, and the DOJ 
do not coordinate their actions to deter these bad corporate 
actors.
    As the Director of the Center for Program Integrity, have 
you worked with HHS IG and the DOJ to implement any shared 
policies or guidelines among the agencies that will help assure 
that the actions taken by one agency, like imposing a fine and 
putting in place this corporate integrity agreement, will be 
strong enough to defer future corporate bad acts? What have you 
done since we met last time?
    Dr. Agrawal. Yes, I completely remember that line of 
questioning.
    Senator Warren. Good.
    Dr. Agrawal. So we----
    Senator Warren. I thought you might.
    Dr. Agrawal. We work very closely with the Office of 
Inspector General on a daily basis. We coordinate with them on 
investigations. We make referrals to them on a routine basis. 
We have referred thousands of cases in the last year to the OIG 
for further investigation and their actions.
    They have full access to all of our data analytics and 
other systems so that they know what we are working on. They 
have real-time access to the same data that we do. Indeed, we 
coordinate on cases where if it looks like we want to take a 
revocation action, we coordinate with them and make sure that 
they are aware of that action. There are certain authorities--
--
    Senator Warren. Well, this sounds good. It sounds like you 
are working together.
    Dr. Agrawal. It is promising. There is more.
    Senator Warren. All right.
    Dr. Agrawal. There are certain authorities that they have 
such as exclusion authority, that I think is very useful and 
obviously they leverage whenever they can. That exclusion 
authority goes beyond kicking somebody out of Medicare. It 
keeps that person or that entity from getting any healthcare 
dollars, so we do make referrals of cases to leverage that 
exclusion authority, and another area of collaboration, there 
is a legislative proposal in the President's budget around 
expanding that exclusion authority. We are very supportive of 
that because it is another place where we can work together.
    Senator Warren. Okay, but let me just track this down just 
to make sure--I realize I am running out of time, but I just 
want to see if I can finish this point, so you are working 
together. You are making referrals. Do you know if DOJ and HHS 
IG have official policies or informal practices with regard to 
whether or not they are really deterring future wrongdoing? I 
do not understand how Tenet can keep showing up like this in 
the records, promising not to break the law and breaking the 
law over and over.
    Dr. Agrawal. In my day to day interactions with the IG and 
DOJ, it is very clear to me that they are committed to stemming 
as much healthcare fraud as possible, either by kicking 
entities out of Medicare or the healthcare system or getting 
them into compliance. I think the specific policies they would 
have to reference, but I have seen nothing in my daily 
interactions with them that would suggest otherwise.
    Senator Warren. Well, let me tell you the part I see and 
that is the part where we are watching the same actors appear 
again and again and again, which suggests to me that whatever 
it is you are doing or they are doing is not getting us where 
we need to be, and the consequence of that is we are seeing 
repeating bad acts and the American taxpayers are losing a lot 
of money over this.
    Companies should not be allowed to get away with fines and 
a promise that they will do better in the future and a wrist 
slap. Until we get serious about holding these big bad actors 
accountable when they defraud Medicare and Medicaid, the big 
guys who cheat the system are not going to have a reason to 
stop. Thank you, Madam Chair.
    Senator McCaskill. Thank you. I want to turn it to Senator 
Carper who is visiting our Committee today, but he is welcome 
because this audit, he was one of the primary requesters of 
this audit. He is a one-man vigilante when it comes to improper 
payments. This is somebody who has been on this for as long as 
I have been in the Senate. He has been working on improper 
payments. We are happy to have you today and welcome your 
questions.
    Senator Carper.
    Senator Carper. Thank you. Thank you so much. My thanks to 
you, to our Chair, for giving me the opportunity to come by. I 
used to serve on this Committee and I said to Senator Casey one 
day, Senator Reid said to me, would you like to be on the 
Finance Committee? I said yes. He said would you be willing to 
give up Banking? I said yes. Would you be willing to give up 
the Commerce Committee? I said yes. He said would you be 
willing to give up Aging? I said no. I ultimately gave it up 
and now I no longer serve on any of those Committees, but I am 
glad to be where I am on the others. Thanks for giving me a 
chance. You can come home again and so I thank you for the 
opportunity to come back.
    I may have been a vigilante, but I am not a one-man and you 
have been part of the posse, and God knows Senator Collins has 
been along with Tom Coburn, all of us who have served at one 
time or another on Homeland Security and Governmental Affairs.
    When they asked Willie Sutton, why do you rob banks, he 
says, that is where the money is. There is a lot of money at 
stake in Medicare and Medicaid, and it is a lot to say grace 
over and we acknowledge that and applaud CMS and those who are 
trying to be vigilant in making sure they are good stewards 
with all of those dollars.
    Having said that, I watched with dismay as we learned at 
the beginning of this year that improper payments for last 
year, 2014, did not go down despite all of our collective 
efforts, including all of what we put in the Affordable Care 
Act to kind of strength the hand of CMS to go after improper 
payments, to actually see them go up, and not by a little bit, 
by 20 percent, by $10 billion from roughly $50 billion the year 
before to last year at $60 billion.
    Let me just start off by saying to the representative from 
GAO, Mr. Bagdoyan, why did it go up? Why so much? I was 
astounded.
    Mr. Bagdoyan. Well, thank you for your question, Senator 
Carper. That bit of insight was beyond the scope of our work. 
There may be a range of reasons for that, but I cannot really 
comment on specifics.
    Senator Carper. Okay. Same question, if I could, Dr. 
Agrawal. Why did it go but, just very briefly?
    Dr. Agrawal. Sure, thank you.
    Senator Carper. $10 billion, 20 percent after all this 
effort that we put into it. We have, you have.
    Dr. Agrawal. The improper payment rate is definitely an 
area that we are continuing to focus on and appreciate your 
leadership on. We have seen a few major drivers of the improper 
payment rate. One thing that we have seen is as our program 
integrity efforts increase, as we get more vigilant, providers 
can sometimes have a hard time keeping up, which can drive up 
the improper payment rate for a while until they learn our new 
rules.
    One example of that is the home health face-to-face 
requirement which I think is obviously a very sensible policy. 
It makes a lot of common sense, but it has led to now over 50 
percent of home health claims being improperly paid. In other 
words, where the medical record documentation of the face-to-
face requirement is not there, is not sufficient to meet the 
standards of the requirement.
    As you know, certainly, Senator, the improper payment rate 
is not a fraud rate, it is not overlapping with fraud. I think 
these are usually vigilant providers that are trying to keep up 
with the rules that we can do a better job to educate. We can 
also do a better job to move our reviews to a prepayment world 
through efforts like prior authorization, as we are doing, to 
help drive down the improper payment rate.
    Senator Carper. I thank you. Mr. Bagdoyan, has anyone ever 
mispronounced your name?
    Mr. Bagdoyan. Always.
    Senator Carper. Okay. Well, good.
    Mr. Bagdoyan. You are not the first one, Senator.
    Senator Carper. I will try not to do that that as well. In 
his testimony, Dr. Agrawal said that he recognizes the 
importance of the problem that we are talking about here today, 
and he is just trying to take steps to address those problems. 
Could you just comment on CMS's plan for addressing the 
vulnerabilities that GAO has identified? Do you think this plan 
is adequate?
    Mr. Bagdoyan. Sure. Thank you for your question and I 
appreciate Dr. Agarwal stating that CMS has agreed with the 
recommendations, that they have already initiated some steps to 
respond to them, including providing us with responses to the 
referrals we have made.
    I think the absolute key here is sustained execution and 
attentiveness to a strong internal control regime, front, 
middle, and end to help address some of the issues that we 
identified.
    Senator Carper. All right. Dr. Agarwal, your testimony 
demonstrates, I think, fairly clearly that you and your 
colleagues take seriously what GAO, the findings of GAO, and 
you stated your commitment to addressing the identified 
vulnerabilities. Could you just give us a little more detail as 
to when you will have implemented these steps and what is your 
timeline for closing the vulnerabilities described by GAO?
    I will just say, for me, one of my frustrations here is we 
have all heard the term low hanging fruit. This is not low 
hanging fruit we are talking about. This is a fruit that is 
laying on the ground. I just want to hear a sense of urgency 
that we are going to seize this day, we are going to seize this 
day. Go ahead.
    Dr. Agrawal. Absolutely, Senator, and we do have a sense of 
urgency. We have staff that are focused on provider enrollment 
every day as their main job and they want to get all of these 
bad actors out of the program as well. For example, when it 
comes to ineligible addresses, the GAO has recommended on-
boarding a new data base through the USPS to essentially 
replicate the work that they did. We agreed with that 
recommendation.
    The time for--we need a certain amount of time to get 
access to the data base, verify it, get it incorporated into 
our systems, and so we are targeting doing that by early next 
year. However, in the intervening timeframe, we are also going 
to do other work as we on-board the final fix.
    One is we are going to be doing more ad hoc site visits of 
these limited risk providers since again, those were the ones 
that kind of fell through the cracks in our screening process. 
We are going to do several thousand site visits right away and 
then work to ramp that up in the coming months.
    When it comes to mailboxes, we are also going to 
immediately start comparing lists of the CMRAs, these 
commercial mailbox agencies, bump that list up against PECOS. 
We are going to do that on a routine monthly basis and then, 
you know, visit, investigate, whatever comes out of that in 
this intervening phase until we get this data base 
incorporated.
    Senator Carper. All right. If I could, Madam Chair, you and 
I worked for a lot of years on postal reform and one of the 
things we have tried to do is to help the Postal Service figure 
out how to take a 200-plus-year-old legacy distribution network 
and find new ways to make money out of it, to monetize it in a 
digital age.
    It occurs to me that in a time when we have thousands of 
so-called Medicare providers that are operating out of a 
mailbox or that may be operating, if you will, out of an empty 
building or a vacant building, a vacant lot, you have got the 
Postal Service over here that literally knows what is there, 
what is there in each of these delivery sites.
    There has got to be some way that the Postal Service is 
looking for a way to make money. They have this information. 
There ought to be a way to provide a great partnership, which 
enables the folks at CMS to save a ton of money in Medicare and 
provide, frankly, a revenue stream that the Postal Service 
could use.
    I am going to pursue that and my hope would be that the two 
of you would join me in that pursuit. Thank you so much for 
letting me come by. Thank you.
    Senator McCaskill. Thank you, Senator Carper. We are 
thrilled to have you here today.
    Senator Casey.
    Senator Casey. I want to thank Senator McCaskill for this 
hearing today. Madam Chairman, I thank you as well. I thank 
both of you for this opportunity and for your work a lot of 
years working hard to make sure we are doing everything 
possible to root out waste and fraud.
    Look, I am a believer that when you have any program, 
especially one as consequential and significant in the lives of 
Americans as Medicare whenever you have waste, fraud or abuse, 
that is a taking. It is like stealing resources from people 
that need it, and apparently people that are both vulnerable 
and their families have a reasonable and legitimate expectation 
that the program will be secure, that will be efficient, and 
that the services will be delivered, and services means quality 
care.
    This is serious business and we cannot do enough to make 
sure that we are insisting on much greater strides than we have 
made to date on rooting out waste, fraud and abuse, so it is 
both a taking, but I think it is also an issue that arises in 
the context of our own responsibilities. If we say we support a 
program, we must be willing to support strategies to root out 
waste and fraud.
    We are grateful for the efforts so far, but we have got a 
long way to go. Every minute of every day that there is waste 
and fraud in a program like this, it gives legitimacy or 
momentum to those who would like to slash a program. You cannot 
just be for a program and be for funding if you are not going 
to be for the integrity of the program.
    I wanted to start with Dr. Agarwal and I may not get to our 
other two witnesses, but I wanted to ask him at least two 
questions. First, was on Senior Medicare Patrol, which, as you 
know, is legislation that was--I should say the program itself 
is part of our law for a number of years now.
    We had an extension added to the Older Americans Act and we 
know the basics of what that Medicare patrol does. It helps to 
educate Medicare beneficiaries and their families about how to 
spot and report waste, fraud and abuse. We know that through 
the year 2013, the program saved Medicare 120 million bucks and 
that is not bad.
    I was noticing the error rate in Medicare, that is a lot 
more than $120 million, but it is a contributor. This program 
is a contributor to that goal of rooting out waste and fraud, 
so using that as kind of a point of departure, Doctor, that 
program, is that something we can build on? Is that something 
we can replicate or enlarge?
    Dr. Agrawal. Yes. I am a big fan of the Senior Medicare 
Patrol. We do work closely with that program. I speak routinely 
with that organization. In fact, next week we have another 
meeting. One of the biggest things that we have focused on from 
a beneficiary standpoint is the use of the Medicare summary 
notice or the EOB to make sure that beneficiaries are aware of 
and educated about their health care utilization patterns and 
making sure that they give us leads if they see something on 
the MSN that is not accurate.
    We get 40,000 complaints from beneficiaries related to 
program integrity alone and use that information in our 
automated practices. We have it as part of our predictive 
analytics system. We use it in investigations. Many of those 
complaints have led to significant investigations and outcomes 
for us, so I think that is certainly a foundation we build on. 
The agency conducts an annual sort of educational campaign for 
beneficiaries, particularly around the open enrollment periods, 
to make sure that they are aware of program integrity efforts, 
how to protect their private information and things like that.
    Senator Casey. Are there other resources or tools that you 
would need to accomplish that or you think you have the 
resources you need right now?
    Dr. Agrawal. You know, I appreciate the question. I think 
we are building on the foundations that we have. I think there 
is lots that we could do with beneficiaries. That relationship 
clearly matters a lot. There are potentially 50 million 
investigators on the ground for us, so I would not make a 
particular ask at this point. That might be unusual, but no, I 
really appreciate the support around this kind of program and 
the support of the beneficiaries that we have.
    Senator Casey. I appreciate that. Second, before I wrap up, 
I will put it on the record. It might be a brief answer and you 
could amplify it in writing, but the provider screening 
process. We, of course, want to get the balance right between 
being thorough and vigorous and making sure that the process is 
strict and thorough, but at the same time make it fair and 
navigable. I guess the basic question I would ask you is, do 
you think you are getting that balance right or do you think we 
have got a ways to go on that?
    Dr. Agrawal. I think you are absolutely right about the 
need for balance. I think we think about that balance on a 
daily basis in our work. I think as long as we have one, you 
know, illegitimate provider in the program, we need to continue 
to be vigilant. I think that balance is something that we need 
to continue to work to achieve, but we are not there yet on the 
numbers, and like I said, if there is one, we need to get them 
out of the program.
    Senator Casey. Thanks very much.
    Senator McCaskill. Senator Cotton.
    Senator Cotton. Thank you. Thank you all for attending 
today. Mr. Bagdoyan, thank you in particular for the good work 
that you and the GAO have done on this issue. In your years of 
doing this, but especially over the last year since the CMS 
changed the steps that are necessary for verifying information 
of Medicare providers, do MACS tend to take steps over and 
above what CMS requires of them?
    Mr. Bagdoyan. Thank you for your question, Senator Cotton, 
first of all. I think based on what we have encountered during 
this work, the MACS seem to be following the guidance that 
originated in March 2014. In fact, we encountered a couple of 
instances where the MACS, pretty much acting on that guidance, 
actually verified providers that should have been flagged for 
potential action.
    Senator Cotton. What were some of the main reasons why they 
verified those providers that should have been flagged? What 
was omitted? What did they not check that they might have 
checked if the CMS steps were slightly different?
    Mr. Bagdoyan. From my recollection, basically what they did 
is they made calls to a single location and asked over the 
phone to see whether the address that they had on record was 
the actual address for providing services.
    Senator Cotton. Some of the examples are pretty arresting, 
you know, of addresses that are open fields or fast food 
restaurants or so forth. Would it be possible to verify or at 
least provide a more complete picture needed for verification 
by, say, using Google Maps?
    Mr. Bagdoyan. Sure. That is part of our analytical approach 
to our work. What we did was we started with the USPS address 
data base and then we employed the Google Maps, we did Internet 
research.
    Senator Cotton. When you are saying we, you are saying the 
GAO?
    Mr. Bagdoyan. This is my colleagues and I on the team, yes. 
We looked at the providers' purported websites and then on 30 
occasions we had a site visits including taking photographs, 
some of which were displayed earlier today.
    Senator Cotton. Do you think that is an onerous process?
    Mr. Bagdoyan. Well, I think we did it with a fairly small 
team. It is work, but as you see from the results of our 
report, it is solid work. We certainly stand by it. I am very 
proud of my colleagues for doing a great job, and these are 
things that are available to be done, the commercially 
available USPS software, for example, and the Internet, site 
visits. Those are all things within one's purview.
    Senator Cotton. Certainly the Internet and Google Maps.
    Mr. Bagdoyan. Sure.
    Senator Cotton. Or MapQuest, to be agnostic about one's 
preferred choice.
    Mr. Bagdoyan. Whichever works best for the circumstance, 
yes.
    Senator Cotton. Dr. Agarwal, do you think it is too much to 
ask MACS to say, use Google Maps or MapQuest, at least to see 
that providers are not using addresses that are fast food 
chains or UPS stores or empty lots?
    Dr. Agrawal. We perform similar tests as what the GAO had 
utilized in the generation of this report. Again, as I stated 
earlier, we do appreciate the work of the GAO and these 
findings. We conducted 220,000 site visits since new enrollment 
and screening standards were implemented. We have revoked 1,300 
providers for being non-operational due to those site visits. 
We conducted similar work related to the leads that the GAO 
gave us.
    Overall, we are moving toward an approach that is more 
automated, so one thing that we will be doing as a result is 
folding in the data base identified by the GAO which will 
augment existing data bases that we have that do licensure 
checks, address checks.
    If there is a way to enhance those things, we are 
absolutely looking forward to doing that, but what we want to 
move away from are lots of potentially inconsistent manual 
checks, rather, a system that is highly automated with very 
timely data and MACS are free to elevate their levels of 
concern and trigger even non-required site visits if there is 
anything potentially concerning about an enrollment.
    Senator Cotton. Well, automation is great and centralized 
data bases are great, but we have seen the Government does not 
have the best track record with those. Using something as 
simple as Google Maps or MapQuest would seem to be a reasonable 
step to ask MACS to take, would it not?
    Dr. Agrawal. Well, we have geospatial software in our 
system. Again, you know, I think with the risk of potential 
variability in how different operators, different contractors 
do the work, we have opted toward a system that is much more 
consistent, much more automated, and yet, still gives the 
contractors all the tools they need to do the work. I think GAO 
has identified a good tool that we will be incorporating into 
those, rather than making a significant strategic change and 
moving back toward manual processing.
    Senator Cotton. How are these MACS held accountable 
whenever they make an inaccurate verification, in particular, 
when it could be so easily confirmed as visiting the site or 
even using an Internet search engine like Google Maps or 
MapQuest?
    Dr. Agrawal. Sure. We hold MACS like other contractors 
accountable in a similar manner, so we assess their performance 
on a routine basis. We conduct our own site visits of the 
contractors to make sure that they have the right tools, 
processes, operations in place to do the work.
    We look at the performance metrics and where necessary, we 
take actions like expressing letters of concern reflecting our 
findings in their performance reviews, and then, you know, 
increasing scrutiny from there as necessary, putting them on 
corrective action plans, for example.
    Senator Cotton. Well, thank you. My time has expired, but I 
do think some more work is probably needed.
    Senator McCaskill. Thank you, Senator Cotton.
    Senator Donnelly.
    Senator Donnelly. Thank you, Madam Chair. You know, one of 
the areas that is growing very fast is data analytics, big 
data, data mining. The Chair's--St. Louis Cardinals use all 
kinds of data analytics, can tell you exactly where the ball is 
going, how many times it rotates on the way in is a curveball.
    Senator McCaskill. The best record in baseball.
    Senator Donnelly. For now.
    As you look at this, there are markers that will indicate 
to you, when they do data mining, they can tell exactly what 
that 59-year-old male who happens to like Coca-Cola and this 
particular ball club and this matter and this matter and tell 
you from all of those exactly what they are going to do next. 
This is all predictive. This is all easily determined.
    You can put about 20 markers together and find out very, 
very quickly who your top suspects are and where you can go to 
find them, use the Google Maps that Senator Cotton talks about, 
and go locate them, but an extensive use of data analytics can 
completely change this. I am wondering what your plans are in 
that area, and have any of the biggest data analytics firms in 
the country taken a look at the processes you are using and 
said, hey, this is up to snuff or not?
    Dr. Agrawal. Yes, I absolutely agree that data analytics is 
vital to program integrity work, especially in a system with 
the volume of Medicare. For that reason, three years ago, we 
began implementation of the fraud prevention system which is 
exactly the kind of system that you are describing. It is the 
claims analytics system that looks at all 4.5 million claims 
that come into Medicare every single day.
    That was, again, a sizable change from the historic 
approach to processing claims which was just to pay them. We 
now have eyes on our--automated eyes on every single claim 
looking for outlier claims and outlier providers. That system 
allows us to implement predictive models that are exactly as 
you describe, multi-variant models that are trying to identify 
outlier behavior that is highly indicative of waste, abuse or 
fraud. We base those models on historical patterns, on other 
data analytics, on conversations and discussions with law 
enforcement.
    Senator Donnelly. Then the next question is, with all of 
those, how did we go up 20 percent last year?
    Dr. Agrawal. Well, I think the improper payment rate is 
different from the fraud rate, so you asked if we had had 
anybody come in and assess the system. The answer is yes. The 
OIG came in and did an assessment of our fraud prevention 
system.
    Senator Donnelly. Anybody outside of government, anybody 
who are the very, very best in the data analytic field?
    Dr. Agrawal. Well, I will remind you that our contractors 
are private-sector contractors and the scrutiny that the system 
has faced has been higher than any predictive analytics system 
in program integrity, and what the OIG has found and certified 
as a ten to one ROI for the system, that is still different 
from the 20 percent rise in the improper payment rate, and that 
is because improper payments are not the same as fraud.
    Most of the time, improper payments are lack of appropriate 
documentation or the ability of the provider to substantiate in 
the medical record what they actually billed to the agency. We 
do not see medical records at the time of claims payment or 
actually very, very few of them, so 60 percent of the improper 
payment rate is just from that documentation issue.
    Senator Donnelly. As you look at the data analytics and the 
opportunity to do data mining and you have private-sector 
companies that are providing this to you, what do you do 
continue to make sure that you have best practice modeling 
going on with this?
    Dr. Agrawal. I think that is a great question, so one thing 
that we are required to do by law is to re-procure the system 
periodically. We are actually in the process of doing that, 
which allows us to compete again the system, what our needs 
are, to make sure that if there is a company that is now doing 
better at it than the ones that we have, we will get the 
appropriate company in the door.
    We continue to work on refining models. We implement new 
models on an annual basis, really on quarterly cycles, as well 
as refine models that are already existing in the system to 
help improve their accuracy and the impact that they deliver.
    We are also moving the system into other arrays now that we 
have proven its worth and the positive ROI to the taxpayer, 
focusing mainly on the worst cases like fraud. We are going to 
apply the system against other patterns that are concerning 
like waste and abuse, implementing things like system edits and 
other models so that we can really start to tackle some of the 
biggest areas of losses in the program.
    Senator Donnelly. Ms. Leff, when you look at the fraud 
prevention activities that CareSource and other private 
companies use, do you have any suggestions that CMS should 
adopt that could help them to do a better job?
    Ms. Leff. CMS--we have worked very closely with CMS on 
many, many programs. For example, the Health Fraud Prevention 
Partnership, which I think is a phenomenal collaborative effort 
that pulling data together from all the plans and putting it 
together running algorithms trying to identify fraud from a 
bigger perspective, I think that is going to be a phenomenal 
thing going forward.
    I certainly encourage, you know, that process to continue. 
The prepay system, predictive analytics are certainly another 
area that I think is very important in the fraud space. We in 
the past have always depended on post-payment fraud detection 
systems that had known fraud schemes built in, so it was only 
looking for certain things.
    These new predictive systems, and they can be morphing 
every day, every week, have phenomenal capability to find 
abberancies that most of us could not find on our own, so using 
those new technologies are just very crucial.
    Senator McCaskill. Thank you. Thank you, Madam Chair.
    Senator Whitehouse.
    Senator Whitehouse. Thank you very much. Let me first thank 
Mr. Bagdoyan and GAO for their work that led to this hearing. I 
was one of the signators of the original letter requesting this 
report, and I know that the Chairman and the Co-Chairmen--are 
you Chairman and Ranking Member?
    Senator McCaskill. I am the Ranking Member. She is the 
Chairman.
    Senator Whitehouse. Chairman and ranking member have been 
very energetic in pursuing this and making sure that we had 
this hearing. I express my appreciation to Senator Collins and 
Senator McCaskill as well, but job well done. I am glad we have 
this report.
    There is another report that was done by the Office of 
Inspector General for the U.S. Department of Health and Human 
Services about questionable billing in geographic hot spots, 
and I am wondering, Mr. Agarwal, what you think the geographic 
hot spot effect is for Medicare fraud? My layman's impression 
is that there are places where this is an industry, like 
Florida, and there are places where people rent a place, set up 
shop, send out millions of dollars in bills.
    As soon as they get a big pile, close the doors and they 
are gone and they move on. Hard to pull that off in Rhode 
Island because everybody kind of knows each other. We are a 
small State, but I do have the impression that there are 
serious geographic hot spot issues here and I wonder if you 
would comment on whether that is the case and what you are 
doing to look into that question.
    Dr. Agrawal. Sure, and let me just start by confirming 
Rhode Island is not a huge hot spot for us, so there are. I 
think what you see when you look at almost any healthcare 
system, including Medicare utilization, is that there are 
significant geographic variability. A lot of internal and 
external folks have commented on that. In the particular area 
of fraud----
    Senator Whitehouse. Geographic variability consistent 
through time, i.e., it is the same places?
    Dr. Agrawal. Correct.
    Senator Whitehouse. Okay.
    Dr. Agrawal. Specifically in fraud, there are certain hot 
spot areas that do always, it seems, tend to originate schemes 
and kind of spread them from there. South Florida, obviously, 
is an example, Detroit, Southern California around Los Angeles, 
the Brooklyn area in New York. These are areas that come up all 
the time.
    Senator Whitehouse. What have you done to focus on those 
areas?
    Dr. Agrawal. We take an approach that obviously is looking 
at the entire country. We have regionalization, to some degree, 
through our contractors, but our strategic focus has been to 
create national resources that can still focus on these areas 
as needed.
    One thing that I just discussed was the fraud prevention 
system, this predictive analytics system. Our contractors that 
are regionally based can actually tell us about specific 
schemes that they are encountering in their area, so it might 
be geographically very specific, but we can get those in as 
models into the FPS. That will be then primarily for those 
contractors, so these models can be both national in scope, but 
also be designed to address particular pockets of issues.
    Senator Whitehouse. Where there are geographic pockets, let 
me suggest that you try to establish working relationships with 
local investigative authorities. We have a Medicaid fraud 
control unit in Rhode Island that is part of the Attorney 
General's office. Every State has one. If folks are cheating 
Medicare, they may well also be cheating Medicaid, and so, you 
have kind of a natural group of allies there.
    I noticed that your hot spot areas you mentioned were all 
in very big states, Florida, Michigan, California, so it may be 
that the Medicaid fraud control unit has so much span there 
that they cannot really focus, in which case you would have to 
look at district attorneys.
    I would encourage you to follow Senator Cotton's suggestion 
that there are people who would be willing to take a drive by, 
if you had the relationship with them, to say, look, we just 
got billed a million dollars out of this address in the last 
month and nobody has ever billed us from that address before. 
Would you mind just go checking it out? If it looks like it is 
an abandoned garage, boom, you have learned something. I would 
encourage you to do that.
    The other thing I would suggest, and I would ask you to 
comment on this, is that there are prescription drug monitoring 
programs out there. They are kind of an under-utilized thing. 
It is not quite clear who owns them. It is not quite clear, you 
know, where they--there is a lot of variability State to State.
    The HHS IG report was heavily about the problem of opioids. 
I wonder what your thoughts are and how you are working with 
the prescription drug monitoring programs in the states and 
trying to develop them to the point where they are a valuable 
asset for your anti-fraud as well as anti-opioid abuse efforts.
    Dr. Agrawal. Sure. Let me just say on the first point, we 
totally agree. I totally agree that a relationship with local 
entities is extremely important. Our contractors are indeed 
required to work with local law enforcement entities, including 
regional OIG offices. We also have Federal staff located in 
many of these hot spot areas so that we can address the hot 
spots directly.
    To your second point about opioid utilization, there is a 
variety of programs in place at CMS, primarily through the Part 
D program and Medicaid, to address opioid over-utilization. We 
look at prescribers of these medications as well as the 
beneficiaries who utilize them. We have controls, utilization 
management protocols, case management approaches to the 
beneficiaries, and then we have the same oversight approaches 
to the prescribers that we do in the rest of the program, 
including enrollment and screening, claims analytics or 
prescription analytics, and investigations, so you know, we are 
doing more and more to incorporate Part D into this overall 
work. In the Medicaid work, of course, we have to work very 
closely with states in their monitoring approaches so that we 
are addressing providers that might be particular to the 
Medicaid program.
    Senator Whitehouse. If I could, with the Chairman's 
permission, make a query for the record, I would like to ask 
Dr. Agrawal to have the opportunity to respond in writing to 
where they see themselves going with the PDMPs, prescription 
drug monitoring programs, as an enforcement and public safety 
device. That way I do not have to use any more of my time since 
I am over it.
    Senator McCaskill. Certainly.
    Senator Whitehouse. Thank you.
    Senator McCaskill. Thank you. Thank you, Senator. Senator 
Collins.
    The Chairman. Thank you very much. Mr. Bagdoyan, I want to 
go back to a comment that the doctor made in his opening 
statement. He said that both the hamburger joint and the vacant 
lot had not received any payments in 10 years, and in the 
interest of time, I am going to focus on the vacant lot.
    That comment bothered me greatly because it was so 
dismissive of the concern that brings us here today. According 
to the GAO report, and I am looking at page 21, GAO made a site 
visit and found that the lot was vacant in December 2014. Is 
that accurate?
    Mr. Bagdoyan. That is accurate, Senator.
    The Chairman. Then according to GAO, the provider went 
through a re-validation process using this vacant lot as the 
address and was approved by the MAC the very next month, in 
January 2015. Is that accurate?
    Mr. Bagdoyan. Looks to be, yes.
    The Chairman. Does that not mean that the provider remained 
eligible to bill Medicare in the future from that lot as long 
as you are in the provider system, the PECOS system. Is that 
accurate?
    Mr. Bagdoyan. That is the risk, Madam Chair.
    The Chairman. Is that not the problem? Even if someone has 
not billed from an address in some time, if they remain in the 
system and eligible to bill, then the potential for fraud is 
still there.
    Mr. Bagdoyan. That is correct, yes.
    The Chairman. Doctor, I want to turn to another issue that 
we did not complete on providers that have had their licenses 
either revoked or suspended and yet are still eligible for 
Medicare. Is it correct that CMS primarily relies on self-
reporting by physicians?
    Dr. Agrawal. Providers are required in their enrollment 
application to self-report license information. However, we 
have, in recent years, implemented the automated provider 
screening system which then does continuous monitoring of 
licensure, which is what has allowed us in these--since the APS 
was created, to revoke 11,000 providers for licensure issues, 
so no, we do not rely entirely on self-reported data, but of 
course that is part of the enrollment application.
    The Chairman. Sure. Someone who is determined to keep 
drawing money out of the system and is not ethical and has had 
his or her license revoked is not likely to report honestly, 
are they?
    Dr. Agrawal. Well, correct. That is why we have implemented 
other data checks around exactly those issues, and where a 
provider has falsely reported information, we can take action 
against them. The reporting is actually useful as a lever for 
that purpose, because that, in and of itself, if they have 
inaccurately reported data to the agency, we can kick them out 
of the program for that reason, so getting the reports is 
actually useful for us from an investigative standpoint.
    The Chairman. Do you use the Federation of State Medical 
Boards data, the FSMB data, as a check automatically?
    Dr. Agrawal. We go upstream of the FSMB, actually going 
back to the states themselves. Since the FSMB is an umbrella 
organization for the states, they get information from the 
states, so what we have done to try to get more accurate, more 
timely information, is to go back to the states themselves, 
which is why we have to use so many different data bases to get 
license information.
    The Chairman. Well, do you use this consolidated data base 
at all?
    Dr. Agrawal. We do. Again, we do and we perform continuous 
monitoring on licenses, which is why we have been able to 
revoke 11,000 providers for license issues.
    The Chairman. Okay. If you are doing continuous monitoring, 
how is it that GAO was able, in a relatively short time, and 
not doing--and not that it took years and years--to come up 
with hundreds of providers that had had their licenses either 
revoked or suspended, and yet, under your system, were still 
eligible?
    Dr. Agrawal. Yes. I think it is important to keep in mind 
that there were 19 providers on the list that we ultimately 
took an action on against--you know, with GAO's input and 
recommendations. I think where the GAO has clearly added a lot 
of value----
    The Chairman. Well----
    Dr. Agrawal. Just permit me to answer the question because 
I think it is important.
    The Chairman. Sure, certainly.
    Dr. Agrawal. Thank you. Where the GAO has clearly added a 
lot of value is they said to us, we should be monitoring more 
than just the licenses of active enrollments, the licenses for 
states in which a provider is actively enrolled, but looking at 
the provider's entire set of licenses. That is an enhancement 
of the program and enhancement of the use of our continuous 
monitoring system. We agreed with that approach and we are 
implementing that change so that additional licenses are being 
monitored in the system.
    The Chairman. Mr. Bagdoyan, do you agree that there were 
only 19 physicians on that list? It was my understanding that 
you had not gotten a report back from CMS despite it being 
overdue.
    Mr. Bagdoyan. That is right, Madam Chairman. We would be 
happy to look at what CMS provides us in response to our 
referrals, which is a matter of routine for my mission team. We 
do that, work closely with the agencies to make referrals for 
action on their part and a response to us in terms of what they 
have done, so once I have had a chance to look at the details, 
we would be happy to consider any additional actions.
    The Chairman. I would officially ask you on behalf of the 
Committee to undertake the review that you did of the referrals 
to CMS, compare it with the response we have received today, 
that there were only 19 physicians on that list who warranted 
being kicked out of the Medicare program, and help us better 
understand the discrepancy. It is my understanding that part of 
it is that you referred the names of physicians that were not 
removed until many months after adverse action.
    Mr. Bagdoyan. That is right.
    The Chairman. That obviously puts the system at risk. Is 
that accurate?
    Mr. Bagdoyan. It is. Even though the numbers may be 
relatively small, obviously these are potentially bad actors, 
to use a term of art, so it is important to flag each and every 
one of them to the extent possible. What we are looking for 
here is reasonable assurance, not absolute assurance, that 
everybody is going to be flagged. I had that as an action item 
for followup.
    The Chairman. Thank you, and in fact, I think that one of 
the providers had billed something like $600,000. I mean, there 
can be a lot of money at issue here.
    Mr. Bagdoyan. That is right.
    The Chairman. Ms. Leff, just one final quick question for 
you. If you were to compare your system to that used by CMS, 
what one improvement would you suggest that CMS use?
    Ms. Leff. I think CMS is working on the same issues that 
CareSource is working on. We are looking at new analytic 
systems, predictive analytics. Prepay, I do not know how 
possible that is, but you are doing some of that, I believe, in 
the CMS area.
    I think those are the things right now that seem to be the 
focus in the fraud program integrity area, really trying to get 
ahead of the game, preventing the dollars from going out the 
door, and instead of trying to pay it and chase it and trying 
to get it back.
    The Chairman. Thank you. Thank you.
    Senator McCaskill. Thank you. Mr. Bagdoyan, do you know 
what the amount of fraud is? Dr. Agrawal pointed out that 
improper payments does not mean all fraud. Do we have any 
estimates of what percentage of the improper payments represent 
fraud?
    Mr. Bagdoyan. We do not. It is inherently difficult to 
estimate, so the big top line number is improper payments, some 
of which may be fraud, but it is very difficult to ascertain 
the exact extent.
    Senator McCaskill. Has there ever been an attempt at CMS to 
determine what the level of fraud is on an annual basis out of 
the $554 billion that we are spending on this program?
    Dr. Agrawal. Nothing on the scale of the improper payment 
rate measurement that is done. We have been working on a 
project to essentially pilot some kind of fraud rate 
calculation. I totally agree with Mr. Bagdoyan. That is 
actually very complicated, to try to generate a fraud rate 
since, of course, once you have identified a potential issue, 
you have got to investigate it, you know, take appropriate 
actions, and if it truly is fraud, remove it from the system, 
which inherently alters the rate itself.
    We have started--we have been working on a pilot in the 
home health area. We will actually be piloting that methodology 
very soon working with law enforcement, with other entities, to 
see if we can generate an initial sample in home health of what 
a fraud rate might look like. That will be the first time the 
agency has done such a thing.
    Senator McCaskill. Well, is anybody compiling the cases 
around the country of Medicare fraud that are brought and the 
dollar amounts they represent? I know with some regularity, our 
attorney general trumpets a multimillion dollar settlement on 
Medicare fraud. I am sure every attorney general in the country 
does that. Are you all making any attempt to compile that so 
that we can begin to get some kind of--it is unsettling to me 
that we so easily do improper payments, but we are not doing 
fraud.
    I do not really--I mean, I understand there has to be a 
determination legally that it was fraud, but at least we could 
be identifying potential fraud, just like you are identifying 
potential improper payments. The improper payment figure, there 
is some money included in there that turns out not to be 
improper payment.
    Dr. Agrawal. Well, that is exactly the approach that we are 
trying to take in this home health example that I provided, is 
to look at potential fraud. When you look at improper payments, 
that is a statistical sample of claims that we then compared to 
medical records. It is on the order of, I believe, 100,000 
claims, if I remember correctly, and then it is extrapolated 
since it is a statistically valid random sample.
    That is the improper payment rate in Medicare and it is 
corroborated with medical records. The challenge of determining 
a fraud rate is that you cannot just go to the medical record.
    Senator McCaskill. I understand.
    Dr. Agrawal. You have to conduct a site visit. You have to 
try to get at the intentionality of the provider.
    Senator McCaskill. Could you compile the amount of Medicare 
fraud that has been determined through DOJ and attorney 
generals across the country. Do you do that?
    Dr. Agrawal. Well, that is a good point. DOJ and OIG do 
compile their own casework. They compile, obviously, 
settlements, other actions that are taken, and that we do 
publish on a routine basis.
    Senator McCaskill. What is that number?
    Dr. Agrawal. Well, in our HCFAC report, I believe we have 
reported between seven to eight to one ROI last year in terms 
of dollars recovered in all of these civil----
    Senator McCaskill. I do not want to hear ROI because 
sometimes that justifies a lot of contracts. What I want to 
know is, what is the cumulative amount of Medicare fraud that 
was determined by various agencies, whether it is OIG or DOJ or 
State law enforcement or Agencies, what was the total amount of 
Medicare fraud identified last year?
    Dr. Agrawal. Right. Clearly that is on the law enforcement 
side of the house. We do not keep those kinds of figures. I am 
happy to----
    Senator McCaskill. Well, should you not? Should you not 
know what it is?
    Dr. Agrawal. Well, you know, again, I think fraud is 
determined through very extensive legal process.
    Senator McCaskill. I know that.
    Dr. Agrawal. Our goal----
    Senator McCaskill. That is not my point. My point is, if 
you are sitting there doing your job, the reason we have GAO is 
because they allow us to go in and see how agencies are doing. 
Your job is, in fact, to provide integrity to the program, 
correct?
    Dr. Agrawal. Yes.
    Senator McCaskill. That would be not just improper 
payments, but fraud. Now, if I had your job, one of the first 
things I would want to figure out is, are we getting after 
fraud and are we doing it well? One of the first things I would 
want to ask is, how much do we recover in fraud, how much fraud 
has been identified over the last 10 years? Are we doing better 
or worse? I am puzzled why this is not something you are 
curious about.
    Dr. Agrawal. It is absolutely something that we are working 
to know. However, you know--so what we do is we look at a 
variety of indicators. Where are the cases that we are spending 
most of our time on geographically? What kind of cases are 
they? You know, different utilization areas. We look at overall 
cost to health care or to Medicare and actually see if there 
are changes in that as we press our activities in certain 
areas. There are a variety of indirect indicators that we use 
to substantiate that we are focused in the right areas, 
including, obviously, talking to law enforcement, that we are 
spending our resources wisely.
    I think a basic practical question is, how much time, 
effort, energy, and resources we should spend to determining a 
fraud rate, which at some point becomes an academic exercise, 
as opposed to doing the work and trying to get these bad actors 
out of the program.
    Senator McCaskill. Well, you know, it was interesting. I 
had the same experience when I asked the people at Immigration, 
Customs Enforcement, how many employers they had prosecuted for 
hiring--knowingly hiring illegal immigrants when I first came 
to the Senate, and I actually got an answer that they did not 
know.
    I was stunned that they would not know that, and then they 
said they could not really get me that because it would take 
too much time, too much energy, too many people, so we had our 
interns Google, you know, a few phrases, illegal immigrants 
arrested, employer charged, and we were able to, in a fairly 
short period of time, begin coming up with some significant 
numbers, and when confronted with that, there was some 
embarrassment at ICE about it.
    I guess what I am telling you is, when these prosecutors 
announce it, it is really common knowledge. This is not hard to 
compile. All you would have to do is write a letter to all the 
attorney generals saying, would you send us all the Medicare 
fraud cases that you successfully identified last year and the 
dollar amount. I mean, at least having that--what I am worried 
about is that we are not keeping track if we are doing better 
or worse, so let me go on to the next question. What does 
Finalist do?
    Dr. Agrawal. Finalist is a piece of software. What it does 
is it does similar address verification, although again, we 
agree not to the enhanced level that GAO had undertaken, but it 
does similar address verification activity for CMS in the 
enrollment and revalidation process.
    Senator McCaskill. Was it written for CMS?
    Dr. Agrawal. You know, honestly I am not totally aware. I 
think this was a product that we purchased.
    Senator McCaskill. Do you know, Mr. Bagdoyan? Was this 
written--was this software designed for CMS or was it off-the-
shelf?
    Mr. Bagdoyan. I do not know off the top of my head, Senator 
McCaskill, but I would be happy to get back to you.
    Senator McCaskill. That would be great. I would love that 
for the record, because one of the things we are trying to get 
at is that sometimes Government has a tendency, people come in 
the door and say, we can do this for you, and you get so 
focused on somebody who can do it for you that you do not 
realize there is a product sitting on the shelf like Google 
Maps or like USPS or like other places that you could do the 
same thing, so you said earlier you do not know what it costs. 
Do you know when your contract with Finalist is expiring?
    Dr. Agrawal. I do not.
    Senator McCaskill. I believe you do know, Mr. Bagdoyan, 
right?
    Mr. Bagdoyan. My colleagues can correct me, but I believe 
it is toward the end of this year.
    Senator McCaskill. That is correct, the end of this year, 
so the question is, are there any plans to replace Finalist?
    Dr. Agrawal. Well, I think what is less important to us is 
the specific name of the product or, you know, what a 
particular company has. I think what we want to do is we have 
actually taken the approach that you are describing, which is 
to try to use as many off-the-shelf tools as possible.
    That is why we have rolled into our enrollment systems 
things like the GSA debarment list, the law enforcement 
exclusions data base, other existing data bases that allow us 
to do our work and that do not have to be customized a lot so 
that there is----
    Senator McCaskill. I think that is great.
    Dr. Agrawal. That is definitely the approach that we have 
taken. That is the approach that we will take to roll in the 
USPS system that GAO has identified.
    Senator McCaskill. What I am anxious to know is, when it 
gets near the end of the year, is there someone somewhere in 
CMS that is going to renew the contract with Finalist when 
perhaps it is not even necessary, when perhaps it is much more 
expensive than the products you can get off-the-shelf that 
could easily be programmed together?
    I think the people at GAO could help you with this. They 
are very good at it. They do it for living. There seems to be 
this kind of default in Government. We do not want to do 
anything differently because if we do anything differently, you 
know, it might not work in PECOS and people are going to have 
to learn different software, and then we get these legacy 
customized systems that go on and cost our Government a 
fortune. I will be anxious to hear how much Finalist costs, and 
what I really want to know for the record, I not only want to 
know what Finalist costs, I want to know how long it has been 
used. I want to know whether it was designed and scoped by the 
Government or whether it was off-the-shelf.
    I want to know how much time they have been spending 
adjusting the program, and what, if any, plans are already in 
place to compete it for the end of this year, because I believe 
with what you are trying to do with all the data analytics that 
are out there and all the off-the-shelf programs that are out 
there, I believe you could compete this program, and I am 
willing to bet you are going to be able to save some money, but 
you know, we need to know all this information.
    Dr. Agrawal. Sure. We are--I am happy to get that to you. I 
will just say, Senator, that we definitely do not have the 
mentality that systems that are in place need to stay in place, 
or that off-the-shelf products are not useful to us. We have 
specifically made strategic decisions to try to take advantage 
of existing high-value products, and in fact, do competitions 
between products to make sure that we are on-boarding the ones 
that are most useful.
    Senator McCaskill. Okay. Let me move on to something else. 
If I am fraudulently registering as a Medicare provider and 
somebody calls me and I lie about the address, or if someone 
calls me or I failed to report that I have lost my medical 
license in New Hampshire and I am currently in Mississippi, 
what happens to them? How many of them have been referred for 
prosecution?
    Dr. Agrawal. Maybe those are two different questions.
    Senator McCaskill. Same question. Somebody lying to you, 
you know, whether it is a failure to self-report, adverse 
action, in another jurisdiction, or lying about the address.
    Dr. Agrawal. All right. If it is very clear, we have done 
the investigative work, we found out that they operated in a 
non-operational setting or they clearly lied, we can work with 
law enforcement and consider, in all of those cases, whether to 
make a referral to law enforcement. Then obviously law 
enforcement makes a determination about whether they will 
accept that referral and continue to move it along the process.
    Senator McCaskill. Obviously.
    Dr. Agrawal. We--I mean, I think you know this, but we do 
not engage in the direct prosecution itself.
    Senator McCaskill. Correct. I am asking how many you have 
referred.
    Dr. Agrawal. I can get you a formal number, but I know that 
it is in the thousands just from last year alone.
    Senator McCaskill. Whatever delineation you have, I mean, 
these are all performance measures.
    Dr. Agrawal. Sure.
    Senator McCaskill. We did not ask GAO to do a performance 
audit, but they do a lot of good ones, and these are 
performance measures. It is very hard to judge your performance 
if we have no baseline. If we do not know what fraud was at any 
point in the last 10 years, we have no idea if we are doing 
better or worse.
    The same thing with criminal referrals. There a lot of 
things that we can, if we get a baseline, then if you are doing 
great work, Doctor, then you are going to get acknowledged for 
it. The only thing we have got now is that improper payments 
have gone up by billions of dollars and that does not look good 
for you.
    I am trying to give you some other tools. It looks like to 
me you are trying to get after it. I do not think anybody is 
trying to pick on you here. I think we are just trying to do 
basic oversight. If we could get some basic baseline on fraud 
referrals and those kinds of things, then I think it helps us 
measure your progress in a way that taxpayers really expect of 
us.
    Dr. Agrawal. Sure. We will send you that data.
    Senator McCaskill. Okay, great. Finally, my last question 
is just about the prescription meds. When you were talking 
about that, as you know, it is a huge, huge problem and I think 
it is one that is going to become part of the everyday national 
discourse in this country since so many of our children are now 
dying of heroin overdose as opposed--more in my State dying of 
heroin overdose than in car accidents.
    I think it is true in many, many states in our country, 
that young people are turning to heroin because it is so cheap, 
much cheaper than oxy, much cheaper than Vicodin and Percocet 
that they get on the street, so when you see a pattern of over-
prescription for someone, are you contacting the prescribing 
doctors?
    Dr. Agrawal. Yes, so this is an area of focus for us. One 
of the basic tools that we need is to get these prescribers 
enrolled in the program, because once they are enrolled, we 
would then have the same administrative authorities to oversee 
them, to audit them, ultimately kick them out of the program if 
that is what is required.
    Senator McCaskill. Put them in jail maybe?
    Dr. Agrawal. Again, we would refer them to law enforcement 
to do that, and because our main--you know, our main tool has 
not been in place, you know, we promulgated a rulemaking last 
year, we are working to get 400,000 prescribers enrolled this 
year so that we have that direct oversight with them.
    We have definitely been focusing on referrals to law 
enforcement in the interim because that is a major tool that 
we, you know, of course can access.
    Senator McCaskill. Okay, great. Anything else, Senator?
    The Chairman. No.
    Senator McCaskill. We appreciate all of you being here very 
much, appreciate your work. Please give my best to what I 
consider a home away from home for me in Washington and that is 
that gorgeous building down off of 4th and Mass. where all of 
you hang out at GAO. I appreciate so much the work you do and 
the audits you produce. This was a good one and I think we have 
made some progress today.
    I want to thank you, Doctor, and thank you, Ms. Leff, for 
your contributions, also. I particularly want to thank the 
Chairman because every once in a while she throws me a bone and 
lets me believe that I have some semblance of control over what 
is going on here, which I very much appreciate. I think it was 
a terrific hearing and it would not have happened without her 
agreement and her corporation, and obviously her willingness to 
let us focus on this issue. Thank you.
    The Chairman. Thank you very much and thank you for your 
leadership in pulling this hearing together. Committee members 
will have until Friday, July 31st to submit additional 
questions for the record. I want to note that there were two 
members who were here, Senator Sasse and Senator Tillis, who 
did not get an opportunity to question you even though they 
were here for testimony, and they may be submitting some 
additional questions for the record.
    I want to join Senator McCaskill in thanking all of our 
witnesses today and this concludes the hearing.
    [Whereupon, at 4:10 p.m., the hearing was adjourned.]  
      
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                                APPENDIX

    
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                      Prepared Witness Statements

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                        Questions for the Record

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                       Statements for the Record

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