Medicare Anti-Fraud Measures Are Way Overdue, Says Durable Medical Equipment Industry
The durable medical equipment, or homecare, sector represents less than two percent of the total $400 billion Medicare budget and is the slowest growing sector (2.3 percent DME spending growth from 2005 to 2006 vs. 19 percent growth for the entire Medicare spending). Moreover, Americans overwhelmingly prefer home-based care nursing homes and other forms of institutional care.
Since the early 1990's, the durable medical equipment industry has been pushing Congress and Medicare to impose provider accreditation requirements for durable medical equipment suppliers.
Accreditation is one time-tested way of distinguishing legitimate businesses from fraudulent entities.
While it took Congress until 2003 to pass a law mandating accreditation, it wasn't until several weeks ago that Medicare actually indicated the date by which DME suppliers must be accredited- and that date is not until September 30, 2009. Moreover, in 2006, the American Association for Homecare recommended that CMS adopt quality standards for DME that were far more stringent than those the agency actually adopted in its final standards issued in November 2006.
The Association questions why it has taken Medicare so long to impose effective measures to prevent fraud.
Even before the Medicare program initiated new quality standards and accreditation requirements under the Medicare Modernization Act of 2003, the Medicare program was supposed to conduct an unannounced facility site visit before granting a Medicare supplier number to providers of durable medical equipment. The Medicare program also was supposed to conduct an unannounced site visit at least once every three years in order for the supplier to have its supplier number renewed.
A site visit is supposed to be more than just checking to see if the lights are on at the location. An inspector conducting a site visit has a number of requirements that he or she should be looking for such as verifying delivery slips and checking to make sure there is a complaint file. The inspector should also be looking at the suppliers' patient files. An inspector would be able to spot forgeries.
CMS has the ability, through its private contractors, to monitor utilization data from claims. A spike in utilization for a specific DME item should trigger closer examination. Unfortunately, Medicare does not seem to do this on a regular basis and when they do, it may be a long period of time after the initial aberrations are seen.
Several questions should be asked of Medicare official:
- What Medicare's accountability in the program's inability to prevent bad actors from getting a Medicare supplier number and inability to identify billing irregularities?
- Shouldn't Medicare be able to enforce its current mandates to protect taxpayer dollars?
- How many fraudulent suppliers are caught in their first year or are turned away at the outset?
Medicare and its private sector contractors must do a better job at insisting on standards and other upfront controls that will deny illegitimate operators any chance of taking advantage of the Medicare program.
We have been at the forefront of efforts to prevent fraud, which is why the homecare industry supports accreditation, quality standards, and other steps to help stem illegal activity. Medicare has failed to impose up-front measures that will curb the opportunity for fly-by-night operators to rip off Medicare.
The vast majority of homecare companies are owned and operated by law-abiding individuals. In many cases, these firms are family operations involving multiple generations, who are dedicated to providing the best possible therapies and medical equipment to treat and improve medical conditions for patients at fair prices. Homecare providers serve patients who suffer from a variety of conditions ranging from multiple sclerosis and congestive heart disease to chronic obstructive pulmonary disease (COPD).
U.S. Department of Health and Human Services Secretary Michael Leavitt has called for greater use of home- and community-based health care because "it's not only where people want to be served, but it's radically more efficient."
The American Association for Homecare (AAHomecare) represents providers of durable medical equipment and related services and supplies as well as equipment manufacturers. AAHomecare members serve the medical needs of millions of Americans who require home oxygen equipment, wheelchairs and other mobility products, hospital beds, medical supplies, inhalation drug therapy, home infusion, and other medical equipment, therapies, services, and supplies delivered in the patient's home. AAHomecare's provider members operate more than 3,000 homecare locations in all 50 states.
American Association for Homecare
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