Fighting the $60 billion beast

Medicare leaves a bad taste in Brian Brice's mouth.

Brice, a sales rep for Jeff's Surgical Supply in Edison, N.J., is losing referral sources left and right to other HME providers that, he says, play fast and loose with documentation requirements.

“Referral sources tell me all the time, 'We left you because you ask us for notes,'” Brice said. “I tell them, 'The notes are required.' But it doesn't matter.”

As a result, Brice estimates his salary, based partly on commission, is down 30% this year. But he doesn't blame referral sources and HME providers; for the most part, he blames Medicare.

“They're coming up with these requirements, but they're not following up on them,” Brice said. “I need them to care. I can't be the only one who cares.”

There have been more than a few government and media reports about HME providers in retiree-hotbeds like Florida helping to swindle Medicare out of billions of dollars each year. Sure, these stories need to be told, but I'm with Brice: What about Medicare? Isn't the agency mostly to blame by enrolling bad providers and approving bad documentation?

There have been few stories about that. After flipping through almost two years of HME News, I found two: A GAO report that detailed the government's success getting two sham HME providers enrolled in Medicare; and a GAO report that criticized a Medicare contractor for failing to determine accurate error rates.

In October, the HME industry scored somewhat of a coup, when “60 Minutes” aired an episode that likened defrauding Medicare to “taking candy from a baby.” A former-crook-turned-informant told reporter Steve Kroft that he just sent in claims and Medicare paid them—for months on end.

For the most part, however, HME providers have carried the weight of Medicare's fraud problem on their shoulders on a monthly, if not weekly, basis.

That doesn't seem fair, especially when you consider that, if Medicare did a better job, the government and the HME industry probably wouldn't be at war with this $60 billion beast.

To be fair, I'm sure Medicare doesn't want to enroll bad providers and approve bad documentation. Its hands are probably tied by a lack of resources and funding.

But Brice doesn't buy it.

“Are you kidding?” he said. “I'd be glad to take a job with them. I could walk into almost any company and fine them, just on inappropriate documentation alone. I'd find more than enough to cover my salary for a year.”

That Medicare's unable to see that an ounce of prevention is worth a pound of cure—that should leave a bad taste in any taxpayer's mouth.