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| U.S. Air Force photo/ Staff Sgt. Liliana Moreno |
A $15 billion wound-care billing loophole finally got closed, but Medicaid programs still aren’t flagging their riskiest providers.
The popular quotation (incorrectly attributed to Thomas Jefferson) that eternal vigilance is the price of liberty and freedom could equally apply to the fight against waste, fraud, and abuse in government programs. Whenever lawmakers pass new measures to prevent waste, or law enforcement cracks down on fraud, scammers tend to migrate to some new scheme.On that front, a report recently issued by the House Energy and Commerce Committee summarizing activities in recent months provides a mixed perspective. In some respects, changing policies and greater enforcement have protected individuals and taxpayers. But the fact that committee members introduced 14 anti-fraud measures in conjunction with the report’s release shows that Washington still has more work to do.
Skin Substitute Spending Plummets
The Energy and Commerce report highlighted one point of good news that has emerged in recent months. As a result of reforms put into place by the Trump administration, Medicare spending on skin substitutes has plummeted.
“Skin substitutes” are a category of wound-care products such as biologic, synthetic, or tissue-engineered materials applied to chronic, non-healing wounds. As I had previously reported, this specific category of substitutes has a history of enormous waste and fraud thanks to a Medicare policy that put no cap on what providers could charge for newly introduced skin substitute products in their first six months on the market. Thus, the category experienced a more than 60-fold increase in spending during the Biden years, from $256 million in 2021 to an estimated $15.4 billion in 2025.
Medical providers were introducing “new” — and of course more expensive — skin substitutes every six months, because the providers could charge whatever they wanted for the product’s first half-year and Medicare would pay it. Physicians, who could buy the products at a discounted price and charge Medicare the full rate, were placing as much as $14 million in “skin substitutes” on a single patient to get in on the action.
Beginning this year, the Centers for Medicare and Medicaid Services (CMS) changed its payment policies such that providers could no longer charge unlimited amounts for skin substitutes. And in June, the annual Medicare trustees report compiled by program actuaries noted that due to the “significant policy changes to skin substitute payments starting in 2026 … spending for skin substitutes will decline by more than 90 percent in 2026.” A recent video by CMS Administrator Mehmet Oz noted that this difference in spending alone has moderated Medicare Part B premiums by $11 per month, or $132 per year. The difference amounts to real savings for America’s seniors — not to mention American taxpayers.
Not Classifying Provider Risk --->READ MORE HERE
A Chula Vista mother and daughter were indicted by a federal grand jury for allegedly committing millions of dollars in Medicare fraud, the Department of Justice said Tuesday.
According to the indictment, Blanca Estela Cardenas, a San Diego nurse practitioner who owned a mobile medical and wound care business, and her daughter, Raquel Pasilla, ran a Medicare fraud scheme.
Prosecutors allege the mother-daughter duo billed Medicare for mobile medical services between April and October 2024, during which Cardenas was in prison for an unrelated crime.
Cardenas was technically unable to personally provide medical services since she was in prison, which goes against Medicare regulations.
The indictment alleges that the two continued to submit claims to Medicare using Cardenas's National Provider Identifier, which is a unique identification number issued to healthcare providers by Medicare and Medicaid services.
Prosecutors say that instead, it was Cardenas's daughter who was providing medical services to patients. She does not have a medical license or certification, prosecutors said.
Over the course of six months, Cardenas, 55, and Pasillas, 33, allegedly submitted approximetly $9.5 million in claims to Medicare, of which they received about $5.5 million in reimbursements. --->READ MORE HERE
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