A hypocrite and a telling comment


We get emails all the time from HME providers and other stakeholders pointing stuff out. These emails often sit in my inbox for some time. They're interesting and noteworthy, but there's no way we can write stories about them all.

So in an effort to clean out my inbox (a great activity when you're working at home because it's blizzarding outside and you're avoiding programming the HME News Business Summit), I'm going to share a few of them with you here.

Former provider Dominic Rotella recently pointed out to me that the government is being a bit of a hypocrite in its crackdown on healthcare fraud. You remember Rotella, right? He fought an audit and won and is now suing TriCenturion, the CMS contractor that conducted the audit, for $10 million in damages. Rotella shared two announcements related to the government's healthcare fraud efforts.

The first: The government announced recovering $4.1 billion in improper payments to Medicare providers in fiscal year 2011. The release on this big news had "fraud and abuse" stamped all over it.

The second: The government announced plans to save $370 million this year, and more over time, from improper payments to Medicare Advantage plans. The release on this big news had "problem" stamped all over it, even though it was estimated to be a $12 billion "problem" in 2011 alone.

Note the difference in how the government views Medicare providers and private health plans? As Rotella points out, Medicare providers being paid improperly is "fraud and abuse"; private health plans being paid improperly is "a problem."

Another provider pointed out a comment made by Dr. Doran Edwards on a discussion board for a LinkedIn group. You remember Edwards, right? He's a consultant and former CMS medical director. He wrote:

Round Two absolutely must happen. Law requires the successful launch of two rounds of competitive bidding. Then the Secretary has the authority to apply an across the board cut to all DMEPOS in which significant savings may be realized. By presidential mandate, competitive bidding for all HCPCS codes and across the US and all territories must be completed by 2016. With the mid-2013 launch of Round Two, there will not be sufficient time for subsequent rounds. So it appears that the present process will result in a successful launch of Round Two, a short period of experience and then a determination of a percentage of savings. A rollout to all locations and the majority of HCPCS Level II codes will follow. Various estimates abound but most frequently heard is the figure that about 50% of the current suppliers will be eliminated or forced out of business. As time progresses, the results of healthcare reform, competitive bidding, ACOs and a host of other changes will become clearer. Wise use of resources, business sense and commitment to this segment of patient care will be required for the winners to survive and maybe even thrive.

The provider wrote that he thought the most telling part of Edwards' comment was that competitive bidding will result in 50% of providers being eliminated. He sees that as proof that part of the government's goal with the program is job loss.

To me, the most telling part of Edwards' comment was the rallying call to providers for "wise use of resources, business sense and commitment to this segment." He sees that, and I see that, as keys to surviving competitive bidding.

Liz Beaulieu


I have attached the AP article I sent Liz referenced in her above article for ALL to please read. Why? Because the article clearly stipulates this $12 billion "problem" overpayment stems from the Medicare Advantage Plans NOT having "PROPER MEDICAL DOCUMENTATION" does this sound familiar? Jon Blum a Deputy Medicare Administrator is quoted saying this isn't FRAUD it is a PROBLEM. Read Below!

Feds to curb improper payments to Medicare plans
Feb 24, 4:42 PM (ET)

Associated Press

WASHINGTON (AP) - The Obama administration says it's taking steps to fix a longstanding problem of improper payments to private health plans that serve 1 in 4 Medicare beneficiaries. So-called Medicare Advantage plans face tighter audits under a policy issued Friday. The rules say Medicare must pay the plans a higher rate to care for sicker beneficiaries. But previous government audits discovered many claims were not backed up by proper medical documentation. Medicare deputy administrator Jon Blum says he doesn't call it fraud, but it is a problem. The estimated error rate of 11 percent added up to $12 billion in improper payments last year.

The Obama administration says it wants to gradually reduce erroneous payments while maintaining quality. Medicare expects to save $370 million beginning this year, and more over time.

Now The Differences:

Big Insurance Companies with deep pockets overpaid is a problem. The healthcare Provider overpaid is Fraud! The statistics contained in these two articles states the Obama Task Force spent millions in taxpayer dollars and collected $4.1 billion from overpaid providers. Insurance Companies were overpaid a little less than 3x the $4.1 billion collected from overpaid healthcare Provders $12 billion. What was spent to collect from them zero!!! The Obama administration says it wants to gradually reduce erroneous payments while maintaining quality.

Medicare expects to save $370 million beginning this year, and gradually more over time. Operative word "gradually". The $12 billion minus $370 million it expects to save this year leaves $11.63 billion overpaid to Insurance Companies this year!!! These are the kinds of challenges facing the industry and the behind the scenes negotiations that take place. This administrative mentality could also be why medicare has a problem? That is why "We need protection from "The Courts"!!! The Ninth Circuit Court published a Decision February 14th that may give support to The Nichole Medical case!!