Reimbursement

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Friday, February 28, 2003

Q. How does a supplier report fraud and abuse and what happens to the complaint?

A. The DMERCs and the state Medicaid programs are encouraging suppliers to call with information indicating fraud and abuse. Anonymous calls are accepted, but calls from suppliers identifying themselves and providing written documentation will receive priority. Many suppliers state that they have reported companies and carriers did not take any action. It can take long periods of time for Medicare and Medicaid to investigate complaints. If your complaint has validity, some type of action will be taken.

The carrier generally will contact other business associates such as physicians, discharge planners, beneficiaries or other suppliers in their local area. Fraud and abuse must be documented to be able to prove the allegations are true. Suppliers should remember that if it’s not in writing, it did not happen.

Suspected fraud or abuse identified by the carrier will cause an in-depth investigation. Services that are found to be fraudulent will be referred to the OIG or CMS regional office.

The supplier that reported the problem will be notified of the end result.

Suppliers and/or citizens should realize it is in their best interest to report fraud and abuse. The HME industry has not done a good job of patrolling itself. The supplier may report incidents by telephone or in writing. Suppliers should help the carriers enforce and make it difficult for fraudulent suppliers to operate and make money. All suppliers should have to follow the same rules.

Suppliers should take action and assume responsibility for protecting our industry name and image.

Jeanie Lane is an independent consultant with The Med Group. Reach her at (610) 372-5191.

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