Thursday, October 31, 2002

Report: CMS fights fraud too hard
Q: My DMERC has us under scrutiny because we allegedly didn't comply with vague and confusing rules. Now they're threatening sanctions. Suggestions?

A: The era of aggressive, voracious government scrutiny of healthcare providers may be ending, albeit slowly. Too often the government's attitude seems to be "we can find fraud wherever we look, so give us what we demand or you will pay dearly." An expert panel has now agreed that this aggressiveness is a problem, and their comments may help you when trying to resolve problems with CMS, the OIG or your DMERC.

A bi-partisan panel of experts recently conducted a study of the Medicare program and submitted its Report to the National Academy of Social Insurance. Much of the Report, entitled "Matching Problems and Solutions: Improving Medicare's Governance and Management", assesses the federal government's campaign against fraud and abuse in the healthcare industry. The experts endorse the importance of anti-fraud efforts, but conclude that such initiatives have gone too far, stating:

"CMS and law enforcement agencies probably [have] pursued fraud and abuse too aggressively at times . . . ." The report also states that "CMS and its contractors frequently have not given providers clear and concise explanations of coding and billing requirements." One of the report's recommendations is for CMS to hold Medicare contractors (including DMERCs) more accountable for supplying information that is "timely, accurate and easily understandable."

The NASI Report's conclusions about CMS over-aggressiveness and DMERC confusion can be used by HME suppliers when they're under scrutiny for alleged improprieties. If a supplier disagrees with government investigators as to the legitimacy of its actions or its interpretations of reimbursement rules, or disagrees with the appropriateness of proposed sanctions, the NASI Report can be an effective defense weapon.

Neil Caesar is president of the Health Law Center. He can be reacheed at 864-676-9075.