05/29/2026    Paul Kesselman, DPM

$15 Billion Dollar DME Fraud

Becker’s ASC Review recently posted that the DOJ
has settled a fraud case against 8 physicians
involved in DME fraud, to the tune of $1.5B. One
of the physicians was an OB-GYN who signed
numerous prescriptions for DME items for Medicare
beneficiaries who were not her patients. She
agreed to pay Medicare back $507,000 to resolve
False Claim Act allegations. She and another
physician who agreed to pay back about $62,000
were the low folks on the totem pole. There was
one individual who was captured after being a
fugitive who was sentenced to 150 months in prison
for leading and organizing a $61.5M health are
fraud scheme. This involved orthotic braces, foot
baths, and genetic testing for patients who did
not need any of these DMEPOS.

The list goes on and on. I again ask Medicare why
DME fraud is so rampant in the Medicare Fee for
Service world, yet you don’t hear much of it going
in the private sector or Medicare Part C plans.
The reason is simple. There are much tighter
controls on the private and MCR part C plans. More
prior authorization more tightly controlled and
inspected networks, more pre- and post-payment
audits and sooner in the claim submission to
payment cycle.

As a taxpayer, one should be absolutely incensed
at the abysmal job CMS has done in preventing
fraud. One also has to wonder how much the
government is netting back after their
investigations. Tighter control at the enrollment
cycles will no doubt curtail new enrollment but it
will also prevent ethical providers from expanding
into area were more supplier types are needed.

There needs to be better mathematical models
developed to curtail this type of fraud. These
need to be implemented soon after any claims
frequency aberrations are noted. Not until years
later when the $$ has often been transferred
offshore and beyond the reach of the Fed Govt.

For more information on this story, please review:
http://podiatrym.com/go.cfm?n=16150

Paul Kesselman, DPM, Oceanside, NY

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