AAH suggests tougher fraud measures

Sunday, October 26, 2008

ARLINGTON, Va. - AAHomecare last week issued a 13-point plan aimed at eliminating Medicare fraud and abuse. It will share the plan with government officials.

"The homecare sector has zero tolerance for illegal activity, and we are frustrated that the problem seems to be growing rather than shrinking," stated Tyler Wilson, AAHomecare's president and CEO in a release. "So, we are sharing these aggressive new recommendations with Medicare and its contractors, Congress, the Department of Justice, and the FBI in the hope that we can keep criminals away from the Medicare program."

AAHomecare's recommendations:

* Mandate site inspections for all new HME providers: A July 2008 GAO report underscored the need for CMS to ensure that its contractors are conducting effective site inspections for all new applicants for a Medicare supplier number.

* Require site inspections for all HME provider renewals: All renewal applications should require an in-person visit by the National Supplier Clearinghouse (NSC).

* Improve validation of new homecare providers: Additional validation of new providers should be included in a comprehensive and effective application process for obtaining a Medicare supplier number.

* Require additional random, unannounced site visits for all new providers: Two unannounced site visits should be conducted by NSC during the first year of operation for new HME providers.

* Require a six-month trial period for new providers: The NSC should issue a provisional, non-permanent supplier number to new suppliers for a six-month trial period. After six months of demonstrated compliance, the provider would receive a "regular" supplier number.

* Establish an anti-fraud office at Medicare: CMS should establish an office with the sole mandate of coordinating detection and deterrence of fraud and improper payments across the Medicare and Medicaid programs.

* Ensure proper federal funding for fraud prevention: Increase federal funding to ensure that NSC completes site inspection and other anti-fraud measures.

* Require post-payment audit reviews for all new providers: Medicare's program safeguard contractors should conduct post-payment sample reviews for six months worth of claims submitted to Medicare by new providers.

* Conduct real-time claims analysis and refocus on audit resources: Medicare must analyze billings of new and existing providers in real time to identify aberrant billing patterns more quickly.

* Ensure all providers are qualified to offer the services they bill: A cross-check system within Medicare databases should ensure that homecare providers are qualified and accredited for the specific equipment and services for which they are billing.

* Establish due process procedures for suppliers: CMS should develop written due process procedures for the Medicare supplier number process, including issuance, denial and revocation of the Medicare supplier number. The procedures must include, for example, an administrative appeals process and timelines.

* Increase penalties and fines for fraud: Congress should establish more severe penalties for instances of buying or stealing beneficiaries' Medicare numbers or physicians' provider numbers that may be used to defraud the government.

* Establish more rigorous quality standards: Ensure that all accrediting bodies are applying the same set of rigorous standards and degree of inspection to their clients.