Stop the gam­ing of the sys­tem

The Washington Times Weekly - - Editorials -

How best to curb fraud and abuse in the Med­i­caid and Medi­care pro­grams? It’s a multi-bil­lion-dol­lar ques­tion. State and fed­eral prose­cu­tors say they are brac­ing to crack down on the prob­lem, and step­ping up en­force­ment means in­creased re­sources.

Ev­ery an­gle of the Med­i­caid and Medi­care pro­grams is ripe for fraud and abuse. Fed­eral and state prose­cu­tors al­ready are tar­get­ing two hot spots — South Florida and Cal­i­for­nia — where dis­abled pa­tients, se­nior cit­i­zens and other spe­cial pop­u­la­tions are pawns in scams that are gam­ing the sys­tem. Here’s the gen­eral snap­shot Health and Hu­man Ser­vices Sec­re­tary Mike Leav­itt re­cently pre­sented to Congress: “The types of fraud com­mit­ted by the [durable med­i­cal equip­ment, pros­thet­ics, or­thotics and sup­plies, or DMEPOS] in South Florida and the Los An­ge­les metro area in­cluded billing for ser­vices not ren­dered, billing ex­ces­sively for ser­vices ren­dered, and billing for ser­vices not ‘med­i­cally nec­es­sary.’ CMS and its con­trac­tors iden­ti­fied thou­sands of Medi­care ben­e­fi­cia­ries liv­ing in both metropoli­tan ar­eas who are re­ceiv­ing med­i­cal equip­ment — like power wheel­chairs, or­thotics and equip­ment for test­ing their blood sugar — they do not re- quire, based on their med­i­cal his­tory. Thou­sands upon thou­sands of th­ese de­vices are be­ing billed for — and paid — in con­nec­tion with the names of Medi­care ben­e­fi­cia­ries, de­spite the fact that the pa­tients never re­ceived the equip­ment, nor had their physi­cians ever or­dered them. Other con­cerns in­volve the co-pays ben­e­fi­cia­ries paid for equip­ment their doc­tors didn’t or­der and was not de­liv­ered, gen­er­at­ing in­cor­rect records sug­gest­ing th­ese ben­e­fi­cia­ries have DMEPOS items in their pos­ses­sion should fu­ture le­git­i­mate needs oc­cur. Nu­mer­ous physi­cians in both lo­cales said they never saw the pa­tients for which given med­i­cal de­vices or equip­ment had been or­dered; nor, cor­re­spond­ingly, had they or­dered the sus­pect DMEPOS.”

That’s the na­tional pic­ture. Smack in front of fed­eral law­mak­ers’ faces in the na­tion’s cap­i­tal is yet an­other. The Dis­trict of Columbia’s Med­i­caid di­rec­tor has re­quested fed­eral prose­cu­tors “to in­ves­ti­gate the find­ings of an in­ter­nal health de­part­ment re­view of two D.C. Med­i­caid health plans that found more than $15 mil­lion in ex­ces­sive costs.” In the case of one firm, au­di­tors found $7.7 mil­lion in “po­ten­tially ex­ces­sive or un­sup­ported costs.” In the other, au­di­tors un­cov­ered $8.1 mil­lion in “im­prop­erly” charged fees.

What’s more is that the re­quest from the city fol­lows an­other au­dit, this one by the D.C. Of­fice of the In­spec­tor Gen­eral, which found the city had over­paid three man­aged-care firms tens of mil­lions of dol­lars over sev­eral years. More­over, last month Mr. McElhatton re­ported that four of D.C. Med­i­caid’s top 10 med­i­cale­quip­ment sup­pli­ers are un­der in­ves­ti­ga­tion, and the of­fices of yet an­other firm were raided by the FBI. The need for broader fed­eral pros­e­cu­tion in the Dis­trict is un­de­ni­able.

The fraud and abuse are, of course, cheat­ing tax­pay­ers across the coun­try. What’s worse is that the real losers are Medi­care and Med­i­caid ben­e­fi­cia­ries. Telling pa­tients who don’t have di­a­betes that they do is un­con­scionable, and then the providers bilk the sys­tem for un­nec­es­sary blood-sugar-test­ing equip­ment. Au­thor­i­ties are also pros­e­cut­ing: doc­tors who are billing for un­nec­es­sary and never-per­formed pro­ce­dures; clin­ics and trans­porta­tion firms that ac­tu­ally never see pa­tients (some of whom are ac­tu­ally de­ceased); med­i­cal sup­pli­ers, phar­ma­cies and nurs­ing homes that are ac­tu­ally us­ing fos­ter-care chil­dren, se­nior cit­i­zens and dis­abled pa­tients as un­wit­ting pawns. One of the most re­cent scams has led to a 41count in­dict­ment that charges four Hous­ton women with billing more than $7 mil­lion worth of equip­ment and ac­cept­ing nearly $3.5 mil­lion in pay­ments. The in­dict­ments say the women con­spired to ob­tain fraud­u­lent pa­per­work from doc­tors who would then claim that wheel­chairs and scoot­ers were med­i­cally nec­es­sary for their pa­tients. The in­dict­ments also say the women used bo­gus pa­per­work to bill Medi­care and Med­i­caid for the high­dol­lar chairs, then pock­eted the dif­fer­ence af­ter de­liv­er­ing the cheaper mod­els.

How much money is di­verted from the ac­tual de­liv­ery of health-care ser­vices to fraud and abuse? That de­fin­i­tive fig­ure is im­mea­sur­able. The cost to Medi­care alone is es­ti­mated at $13 bil­lion. The Se­nate Com­mit­tee on Home­land Se­cu­rity and Gov­ern­men­tal Af­fairs es­ti­mates di­verted Med­i­caid costs at $33 bil­lion. Both Democrats and Repub­li­cans were anx­ious to pass the Medi­care drug en­ti­tle­ment with­out first ar­rest­ing the grow­ing waste, fraud and abuse. The Bush ad­min­is­tra­tion is re­quest­ing an ad­di­tional $183 mil­lion to curb fraud and abuse this fis­cal year. The pro­posal is a solid start to com­bat what ob­vi­ously is a na­tion­wide prob­lem. Congress should act ap­prov­ingly.

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