Interesting approach

 - 
10/16/2008

CMS last week announced plans to roll out a bunch of anti-fraud measures. There were quite a few familiar measures: conducting more stringent reviews of new applications, including background checks; and making unannounced site visits. But there was one measure that caught me off guard:

"CMS is also shifting its traditional approach to fighting fraud by working directly with beneficiaries by ensuring they received the durable medical equipment or home health services for which Medicare was billed and that the items or services were medically necessary," stated the agency's press release.

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This is an interesting approach, one that I've never heard discussed before.

I can see how this would work. Picture this: A fraudulent provider has used a beneficiary's Medicare number without his consent to bill for a piece of DME the beneficiary never needed or received. When CMS calls the beneficiary, he says, "What DME?" Or a fraudulent provider has billed Medicare for a more expensive power wheelchair but delivers to the beneficiary a less expensive scooter. When CMS calls the beneficiary, he says, "What power wheelchair? I have a scooter."

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But I also see how this could blow up in CMS's face. Picture this: CMS calls a beneficiary and asks him whether his power wheelchair is medically necessary. More specifically, CMS asks him whether he uses his power wheelchair outside the home, and he says, "Yes." What then? CMS sends a recovery unit to the beneficiary's house to pick up the medically unnecessary wheelchair?

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If this type of situation unfolds, it might actually work in the industry's favor. Beneficiaries will start associating CMS, not providers, with bad policy.