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Accountable care organization says fraud cost it millions and undermined savings
Summary
David Clobonis of a Palm Beach ACO told lawmakers a single beneficiary was tied to about $9.8 million in paid claims and urged Congress to better prioritize ACO fraud submissions and protect ACO performance payments from external fraudulent claims.
David Clobonis, who testified for a Palm Beach Accountable Care Organization, told the committee that ACOs are both victims and essential partners in fraud detection.
"In 1 case, I publicly shared a single beneficiary associated with over $9,800,000 of Medicare paid claims for anonymous billing," Clobonis said, describing patterns in DME and narrow, high‑reimbursement items billed in massive volumes by newly formed entities. He said his ACO partners with 15,000 clinicians across 30 states and has submitted large sets of suspected fraud, but only a fraction have been reversed.
Clobonis urged Congress to give ACO submissions priority with CMS and to provide prepayment authorities that would allow organizations and government partners to act before funds are irretrievably paid. He also argued that ACOs need protection from reduced shared savings when fraud outside their control drives down performance payments.
His testimony illustrated how provider networks can function as frontline fraud detectors while also suffering financial harm when fraudulent payments are not timely corrected. "If we prevent a $100,000 worth of fraud, that is the same resources that we could use to prevent 6 or 7 readmissions," he told the committee, urging better coordination with law enforcement and CMS.
