Medicare fraud: A hearing, an audit and a bill

Thursday, June 23, 2011

WASHINGTON - With Medicare fraud the mantra of government officials in Washington, D.C., these days, HME industry stakeholders are walking the fine line between supporting efforts to clean up the benefit and saying enough is enough.

At a federal fraud-prevention summit held June 17 in Philadelphia, attendees criticized one of CMS's go-to tools: often-overzealous audits.

"The RACs are set up as bounty hunters and they get paid on what they bring back," said John Shirvinsky, executive director of the Pennsylvania Association of Medical Suppliers, who attended the summit. "(I told them) we are advising all of our members to appeal every request for a payback from the RAC auditors."

It seems as though officials are listening. Peter Budetti, deputy administrator for the Center for Program Integrity, told attendees that, in light of the complaints they were hearing, CMS will conduct an "audit audit" to investigate.

AAHomecare, which also participated in the summit, met with CMS officials June 7. The association offered its recommendations on what documentation should be requested during an audit, as well as recommendations to help clarify how audits are conducted.

"They are open to our recommendations as we work through what we believe are inconsistent applications of rules to claims review," said Walt Gorski, vice president of government affairs for AAHomecare. "While we understand the struggle that they have in rooting out fraud, our main goal is to ensure consistency and accountability in the audit system."

Lawmakers are getting on the bandwagon, as well. On June 22, Sens. Tom Carper, D-Del., and Tom Coburn, R-Okla., introduced the Medicare and Medicaid Fighting Fraud and Abuse to Save Taxpayer's Dollars Act (the FAST Act). While industry stakeholders were still reviewing the legislation last week, a brief look raised concerns that the bill used a "broad brush" approach, said Cara Bachenheimer.

"The government already has plenty of tools," said Bachenheimer, senior vice president of government relations for Invacare. "The question is how do you make the government be smart about going after fraud as opposed to these agendas that impact everybody negatively and ultimately impact beneficiaries. That's the real problem."

One of the tools: predictive modeling technology, which is slated to go live July 1. Similar to what credit card companies use, the technology can detect billing patterns and stop fraudulent Medicare claims before they are paid.

"We are supportive of predictive modeling as a way to spot trends," said Gorski. "At the same time, we are concerned about the circumstances that have occurred with ZPICs and other audits."

For example, if a competitive bid winner's claims volume increases, that should be expected; it shouldn't automatically be viewed as suspicious, Gorski said.

For now, at least, stakeholders say they are just happy that CMS has opened a dialogue with the industry.

"Nobody is more offended by fraud and abuse then those of us who play by the rules," said Shirvinsky. "We have an interest in seeing that the bad actors are eliminated from the system."