Letter: CMS is barking up the wrong tree

Monday, April 23, 2012

In the last several weeks, there have been two CMS announcements, covered by national news organizations, in regard to Medicare fraud. The first is a physician in Los Angeles, Dr. Jacques Roy, charged with a $375 million Medicare scam. Yes, $375 million! He was recruiting the homeless and other indigent people with Medicare coverage and billing for services he never provided, after paying them $50 for their information.

Here’s the interesting part: This scam started in 2006! Over the next five years, this practice billed more Medicare claims than any other practice in the United States. It evidently didn’t come up on CMS’s radar until 2010. The average physician Medicare home health certification per year is 104 patients; Dr. Roy certified over 5,000 patients a year. For five years. Yet, it took CMS until February 2012 to finally bring charges. They barely caught him, as he was evidently getting ready to flee the country.

The other case, which was profiled on ABC Evening News, involved a home health agency recruiting and providing Medicare allowed services to people who did not need them.  They showed a “hidden camera” expose, where an elderly woman, who stated she was in good shape and had no immediate problems, was still provided home healthcare services for which Medicare was being billed. The extent and damage of the operation wasn’t revealed, and when ABC reported this to CMS, they were told that, “It would be looked into.”

It appears painfully obvious to me that CMS is barking up the wrong tree by constantly initiating rampant and capricious audits against DME companies that have proven time and time again that they run an honest business. Certainly, there is still need for policing in our industry, but it should make sense. We are constantly audited and we constantly prevail in more than 90% of our claims at some point in the audit process. Yet, they never stop coming.

If CMS were to re-focus its budget and efforts on physicians and other healthcare providers, I’m confident they would uncover levels of fraud that far outweigh what they’re uncovering with DME. This is where the real fraud is taking place, not with power wheelchair claims. There’s minimal profit in them anymore, so why bother to commit fraud? It’s not worth it to the criminals anymore; there’s more money available by committing fraud in other areas.

Furthermore, beneficiaries that are truly deserving and in need of a healthcare product, like a power wheelchair, wouldn’t be denied the product simply because the paperwork from their physician didn’t meet the stringent and unrealistic needs of the auditing entity.

— Dennis Kline, president & CEO, Source One Medical, Irvine, Calif.