[hmetalk-news]

HHS's Sebelius Admits DME Fraud Was Due to Easy Setup

http://www.ama-assn.org/amednews/2010/02/15/gvsc0215.htm

[Regina]

I am underwhelmed by their "discovery" of how easy it was to become a fraudulent Medicare supplier, and don't have much faith in their claims that they have made it much more difficult.
Now that they have come to this realization, will they stop bothering me for audits on manual wheelchairs?!

[JohnD]

And the article reads in part "Targeting equipment fraud
Prosecuting fraud is one way to help curtail it, but the most effective method is to stop it from happening in the first place, HHS and Justice Dept. officials said.

One example HHS cited was the work it has undertaken to stop fraudulent claims for durable medical equipment. These activities used to be very appealing to criminals because it was easy to set up a fake storefront,...

"All you had to do was rent a room, put some equipment on the shelves, get a phone line and you were set," she said.

And WHERE is the National Supplier Clearinghouse (NSC)? So much for proactive enforcement of existing rules and as a taxpayer I am furious that again the NSC FAILED to perform it's duties.

Shall we go on... ""For example, we were recently able to see that Miami-Dade County, which is home to 2% of Medicare home health patients, has 90% of home health patients receiving more than $100,000 in care each year," said HHS Secretary Kathleen Sebelius. "When you see numbers like that, you don't need a PhD in statistics to know something is going on."
But let's see, in less than 18 months - in ONE COUNTY in the entire US - billings for one series of codes spiked in huge fraud - the 'wheeler dealer scam'. Ms. Sebelius, you don't need a PhD in statistic to know something was wrong... yet again, private companies HIRED BY CMS and paid for by us taxpayers, FAILED to enforce the laws on the books.

[Cuda]

Mirror, Mirror on the wall, who screwed up most of all? NSC! Regina and John D I could not agree with you more. I had a discussion with a representative from CMS who was shocked when I asked when are they going to include the ordering physicians in the fraud equation. I own a billing agency and many of my clients are blacklisted by physicians as being "too difficult" because they request that the paperwork be complete and accurate according to CMS guidelines. These physicians will refer to fraudulent DMEs who present them with pre-filled out forms that only require a signature. If CMS recoups money from a supplier because they don't like the physician's paperwork, then they should also fine the ordering physician. NSC has not stepped up to the plate in years. CMS has not stepped up to the plate in years and instead wasted millions of tax dollars while publicly giving the industry a black eye and publicly expounding on it's talents to deal with the fraud and abuse that they allowed to take place. Just how many audit contractors do they need? If the job was done correctly in the beginning they wouldn't spending millions more on post audits.

[john@valshoes.com]

I have been telling anyone who would listen for the past year that the Medicare fraud problem (at least with new suppliers) starts with NSC's failure to perform its fiduciary responsibilities. The 60 Minutes segment on Miami and LA showed how NSC had let multiple crooks into the system. Worse, the intergrity department failed to identify the fraudulent billings until millions had been paid out. Do you not suppose that recovering these funds was less than 100% or that the costs of recovering funds comes out of taxpayers pocket instead of NSC's pocket?

There is a solution. How about ALL DME suppliers pitch in together to have our patients call or write their elected officials to pass legislation to do two things.

First make it where NSC is on the hook with a mega-surety bond to cover the fraudulent billings of NEW suppliers (and any increase in NSC's surety bond premium cannont be passed on to the taxpayer - has to come off their bottom line). The amount of the bond should be in the amount of what OIG report says occurred from new suppliers the previous year. NSC will have to do ramp up doing their job then to inspect sites and to give out supplier numbers to legit individuals. What do you want to bet that the reporting of fraud will become very accurate and not include billing errors due to overly complex rules and regulations?

Second all NEW suppliers must have a credit limit so if they smoke NSC's inspectors and/or staff, the new supplier cannot bill hundreds of thousands of dollars per day of fraudulent claims during the first 90 days of having a new number. Realistically, what new legitimate supplier is able to provide that amount of services? And if they believe they can, then have legislation in place that says the amount paid per quarter to a new supplier is limited to the amount of the supplier's surety bond. This gives the integrity department time to figure out if a supplier is legitimate or not. It gives a legitimate supplier no ceiling other than their ability to buy a larger surety bond to cover a business plan that exceeds say $15,000 a month in billings that a $50,000 bond covers for 90 days of billings.

Tired of being the whipping boy (or girl) of Medicare because of fraudulent suppliers that NSC let in and that the DMERCs paid fraudulent claims for 90 days? These two approaches solve both issues. But it takes your beneficiaries asking their elected officials to enact legislation. NSC and DMERC insurance companies are not going to change their behavior unless made to by law.