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Sen­a­tors ask providers for fraud-fix­ing sug­ges­tions

Modern Healthcare - - THE WEEK IN HEALTHCARE - Joe Carl­son —with Rich Daly

Ex­perts gen­er­ally agree that a stag­ger­ing amount of money— be­tween $20 bil­lion and $100 bil­lion—in fed­eral spend­ing on health­care pro­grams is lost to waste, fraud and abuse each year de­spite an on­go­ing crack­down by the gov­ern­ment and its pri­vate con­trac­tors.

At the same time, health­care providers com­plain about ag­gres­sive tac­tics, wrong pri­or­i­ties and con­fus­ing guid­ance from the pri­vate com­pa­nies hired by the CMS to in­ves­ti­gate claims of over­pay­ments and fraud.

The Se­nate Fi­nance Com­mit­tee, which has ju­ris­dic­tion over Medi­care and Med­i­caid, thrust it­self into that tug of war last week, is­su­ing an open let­ter to hos­pi­tals, physi­cians and con­trac­tors to sub­mit ideas and feed­back about ways to im­prove the sys­tem to pre­vent waste and fraud in fed­eral health­care pro­grams. The dead­line for com­ments is June 29.

Kim­berly Brandt, chief health­care in­ves­tiga­tive coun­sel for the Repub­li­cans on the Se­nate com­mit­tee, also dis­closed at an in­dus­try con­fer­ence in Las Ve­gas last week that the sen­a­tors have been gath­er­ing in­for­ma­tion in an in­for­mal in­quiry on the CMS con­trac­tors, try­ing to dis­cern “where things are not work­ing, such as with the func­tion­ing of some of the con­trac­tors.”

Don May, vice pres­i­dent of pol­icy for the Amer­i­can Hospi­tal As­so­ci­a­tion, said the Se­nate com­mit­tee re­quest for feed­back from the provider com­mu­nity is likely to be an­swered with com­plaints about con­trac­tors, in­clud­ing the Medi­care Ad­min­is­tra­tive Con­trac­tors, Re­cov­ery Au­dit Con­trac­tors and Zone Pro­gram In­tegrity Con­trac­tors.

“Our con­cern is where you have lots of du­plica­tive ef­forts to try and find sim­ple er­rors, and the mul­ti­ple num­ber of au­di­tors who are out there try­ing to do the same things in very dif­fer­ent ways, cre­at­ing an ad­min­is­tra­tive quag­mire that providers have to wade through,” May said. “It cre­ates huge cost to the sys­tem that isn’t con­tribut­ing at all to pa­tient care.”

Dur­ing a May 1 panel dis­cus­sion at the Health Care Com­pli­ance As­so­ci­a­tion’s an­nual meet­ing, Brandt—who was di­rec­tor of Medi­care pro­gram in­tegrity for the CMS from 2003 to 2010—said find­ing out why the var­i­ous con­trac­tors don’t com­mu­ni­cate with one

an­other about en­force­ment ef­forts is one of the ques­tions the fi­nance com­mit­tee will ex­am­ine.

May said the com­mit­tee is also likely to hear about per­cep­tions that con­trac­tors put too much em­pha­sis on ques­tions in­volv­ing real-time med­i­cal judg­ments, such as whether a pa­tient should be ad­mit­ted for overnight hospi­tal stays rather than treated in a les­s­ex­pen­sive out­pa­tient set­ting.

He noted that news of the Se­nate Fi­nance Com­mit­tee’s ac­tions came on the same day as the mul­ti­a­gency Medi­care Fraud Strike Force an­nounced the ar­rests of 107 crim­i­nal de­fen­dants that were ac­cused of sub­mit­ting more than $450 mil­lion worth of false claims in var­i­ous schemes in cities across the coun­try.

“You’re go­ing to hear: Why aren’t the pro­gram in­tegrity ef­forts fo­cused on where there are real fraud­u­lent prob­lems, in­stead of try­ing to sec­ond-guess a physi­cian who ad­mit­ted a 90-year-old woman who had a mas­tec­tomy, and say­ing she should have been an out­pa­tient,” May said.

Dur­ing a news con­fer­ence an­nounc­ing those Strike Force ar­rests, Mod­ern Health­care asked Dr. Peter Budetti, di­rec­tor of the Cen­ter for Pro­gram In­tegrity at the CMS, about com­plaints re­gard­ing the agency’s fraud and abuse con­trac­tors. Budetti said he wasn’t aware of any spe­cific com­plaints at is­sue.

“We are al­ways aware that when­ever we want to hold some­one ac­count­able, even for pos­si­ble fraud or hav­ing re­tained over­pay­ments, that’s some­thing that in­volves a de­gree of in­ter­ac­tion that some­times raises ques­tions like that.”

Sev­eral in­tegrity con­trac­tors ei­ther did not respond to re­quests for in­ter­views or de­clined to com­ment.

Tim John­son, ex­ec­u­tive di­rec­tor of health­care provider au­dit con­sult­ing firm Jack­son Davis Health­care in Den­ver, said that by and large the CMS’ con­trac­tors do a good job.

“Are there some con­trac­tors out there that do not ap­ply cov­er­age cri­te­ria, or do they ap­ply it in­con­sis­tently? Yes, there are,” John­son said. “Now, is some of that cri­te­ria not pop­u­lar? Yeah. Is some of it vague? Yeah. Does it change all the time? Yeah.”

At the HCCA con­fer­ence last week, some crit­ics took is­sue in par­tic­u­lar with Zone Pro­gram In­tegrity Con­trac­tors, or ZPICS, whose mis­sion in­cludes find­ing fraud­u­lent ac­tiv­ity. ZPICS, they said, are known in the in­dus­try as the au­di­tors who may ac­tu­ally show up at the front door of the doc­tors’ of­fice, hospi­tal or other care fa­cil­ity rather than is­su­ing in­for­ma­tion de­mands through the mail.

“I have ex­pe­ri­enced nu­mer­ous times ZPICS show­ing up and act­ing like they have the au­thor­ity to do any­thing they want,” said Lester Per­ling, a part­ner in health­care law with Broad and Cas­sel. “I’ve had them tell me, ‘I have a right to talk to any­one I want,’” Lester said. “Well, no you don’t.”

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