07/21/2025    Paul Kesselman, DPM

Inside the DOJ's Largest-ever Healthcare Takedown (David Secord, DPM)

Coming from a family deep seated in law
enforcement, David Secord's recent letter
definitely provides the unfortunate reality of why
certain criminal actions are not taken against
specific individuals. However, what his accurate
description of the costs involved does not address
is why it takes so long to build a case or at
least initiate pre or payment review of certain
individuals suspected for fraudulent or criminal
investigations.

Audits can be approved by CMS and instituted by
the Medicare carrier prior to payment and based on
some accepted mathematical formula. This is way
before the FBI or OIG get involved. And way before
any money is paid out and lost to the wind. I am
not calling for the abuse of pre-payment
authorizations as perpetuated by many in the
insurance industry, who now instead become the
criminals and deny needed care. Fair
accountability is what is needed.

Currently, there is a Fee-For-Service Medicare
pre-authorization program in place for certain
knee and spinal braces as well as some select
AFOs. This program has been in place for
approximately two years and has worked very well
with few complaints from providers. Currently, CMS
has a similar program scheduled for Cellular
Tissue Products to be implemented in 2026. This
should be welcome! Second not mentioned in this
forum are the issue of how Whistleblower cases are
prosecuted.

Dr. Secord accurately mentioned there is the issue
of insufficient dollars and simply not enough
Federal prosecutors to go around to handle the
cases. Previously, the Federal gov't allowed
private law firms to act on behalf of the Federal
gov't and bring these cases to court, on behalf of
the whistleblower. That process has pretty much
stopped. While there are many sides to every legal
argument and some may argue that the process was
abused by private entities, the other side is that
this process filled a gap where the Federal
government simply did not have the money or
manpower to handle all these cases.

That was another avenue for bringing these types
of fraudulent activity to justice, either in civil
or criminal court. What most of us should agree to
is that what matters most is to stop these types
of abusive or criminal activities from the get go.

As a retired provider, it shames me to see several
of my profession accused of the activities in the
indictment. This especially at a time when we are
trying to elevate our profession. Just because
there are other physicians (e.g. MD and DO) out
there who are perpetuating many of these
inappropriate acts, does not give our smaller
profession a greenlight to do the same!

What hurts me more, as a Medicare beneficiary, is
the threats to the Medicare and Social Security
trust funds resulting from these actions. As
pointed out by Dr. Secord, even if successfully
prosecuted, how much of this $14.2B will be
recouped and what will be the actual net after
prosecuting expenses? What is needed is action to
stop these acts from occurring in the first place.

Proposed legislation by AOPA (American Orthotics
and Prosthetics Association) would stop drop
shipment of AFOs and other braces and proposes to
eliminate the same and similar rule and provide
other protections for licensed practitioners and
the public. This legislation should be embraced by
every DPM.

Paul Kesselman, DPM, Oceanside, NY

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