December 09, 2022

Warren, Jayapal Urge CMS to Examine ACO REACH Program for Medicare Fraud

“We have long been concerned about ensuring this model does not give corporate profiteers yet another opportunity to take a chunk out of traditional Medicare”

Text of Letter (PDF)

Washington D.C. – U.S. Senator Elizabeth Warren (D-Mass.) and Representative Pramila Jayapal (D-Wash.) led a group of colleagues in sending a letter to Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure expressing concerns about the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) program, which will  start on January 1, 2023 and calling for an investigation into program participants with a history of fraud and abuse. 

ACO reach is a new model Medicare program designed to shift providers from fee-for-service payments to a “value based care” payment system. The program was initially created during the Trump Administration as the Global and Professional Direct Contracting Model (GPCS), but had significant flaws. 

In the letter, the lawmakers raise concerns that the new model could still provide an opportunity for health care insurers and providers with a history of defrauding and abusing Medicare and ripping off taxpayers to further encroach on the Medicare system. They have identified key program participants – including Centene, Sutter Health, Clover Health, AdventHealth, Humana, Vively Health, Cigna, Bright Health, and Nivano Physicians – that were admitted to the program despite a history of Medicare, Medicaid, and VA fraud. 

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

Given the findings of this investigation, the lawmakers are asking that CMS closely examine the participants in the ACO REACH program, including those transitioning from the Global and Professional Direct Contracting Model (GPDC) program, clarify whether previous GPDC participants were automatically accepted into the ACO REACH program without meeting the stated guidelines, and prevent those with histories of fraud and abuse from participating in the newly designed program in 2023. 

“CMS must act quickly to address these risks and protect patients before the new ACO REACH program begins operations by at the very least halting participation by any organizations that have committed health care fraud and terminating DCEs that do not meet the new standards for the ACO REACH program” the lawmakers concluded. 

In the letter, the lawmakers request answers to questions regarding improved screening methods and planning by the CMS to ensure the ACO REACH program is protected from fraud and abuse no later than January 16, 2023.

The letter is also signed by Senators Cory Booker (D-N.J.) and Bernie Sanders (I-Vt.) as well as Representatives Jamaal Bowman (D-N.Y), Cori Bush (D-Mo.), Salud Carbajal (D-Calif.), Peter DeFazio (D-Ore.), Rosa DeLauro (D-Conn.), Debbie Dingell (D-Mich.), Lloyd Doggett (D-Texas), Raúl Grijalva (D-Ariz.), Jim McGovern (D-Calif.), Marie Newman (D-Ill.), Alexandria Ocasio-Cortez (D-N.Y.), Mark Pocan (D-Wis.), Katie Porter (D-Calif.), Ayanna Pressley (D-Mass.), Jan Schakowsky (D-Ill.), Mark Takano (D-Calif.), and Rashida Tlaib (D-Mich.).

In April 2022, Senator Warren led her colleagues in sending a letter to Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure highlighting concerns about overpayments to Medicare Advantage plans that line the pockets of big insurance companies and urging CMS to mitigate the announced payment increases so they are on par with payments to Traditional Medicare. In February 2022, during a hearing of the Senate Finance Subcommittee on Fiscal Responsibility and Economic Growth, Senator Warren questioned witnesses about how corporate profiteering in the pharmaceutical, insurance, and financial industries is contributing to excessive costs for Medicare.