Identifying DME Fraud in Accountable Care Organizations

This document is a case study detailing the investigation into potential Durable Medical Equipment (DME) fraud by an Accountable Care Organization (ACO) operating in Pennsylvania and New Jersey. The ACO oversees care for over 18,000 beneficiaries and has identified significant increases in billing for urinary catheter codes, with a reported rise from $297,339 in 2022 to $2,166,189 in 2023. This 629% increase prompted the ACO to contact the Centers for Medicare & Medicaid Services (CMS) for further investigation. The ACO sought assistance from The Garage to compile necessary data for CMS, which included identifying suspected fraudulent providers and detailing the financial impact. The Garage provided a data warehouse and guidance for creating a PowerBI dashboard to present findings. The investigation revealed a potential shared savings loss of $2.8 million to CMS. The ACO aims to enhance fraud monitoring through new visualizations based on this experience.