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I am all for getting rid of Medicare fraud and abuse. I
understand what a problem it is across every part of the program.
(Some time ago I ran across a scheme that involved fraudulent brain
surgeries even.) I know that the scammers who bilk the system are
costing us money when we don't have any to spare. And I'm glad the
government has finally caught on that it's time to do something
about the situation.
On the other hand, going after the criminals in the HME sector
shouldn't include forcing small providers to the brink of
bankruptcy.
A couple of months ago, I heard from one small Florida company
that had received 90 denial letters from SafeGuard Services, the
Zone 7 ZPIC auditor, on Feb. 1. That was just the beginning.
"Every single day the agency contracted by Medicare to carry out
the audit sends us letters automatically denying the claims for
payment submitted by our firm until all documentation is provided
to them within 30 days, and then we must wait for 90 to 120 days
for payment," according to Carolina Ferreiro-Diaz, the owner of
Pharma-Express in Miami. "We firmly believe that this 100 percent
[prepay audit] that stops payments to our company so radically is
with the intention to put an economic strain on us, as well as on
all of the other providers, and make our business impossible to
operate, thus serving Medicare's goal of having less providers.
"All of this is without any prior history on our part of any
fraud or anything of that sort," she said. Ferreiro-Diaz has
written her senator and hired an attorney. At press time, the
company was "still hanging on," said DME billing clerk Kevin
Cabrera, "but it's getting close."
I recently got a note that paints the same picture from another
small Florida provider.
"We are caught in the middle of a ZPIC," he wrote. "It continues
and is getting worse. Our audits have been going on for six months
now, and we have nothing other than the letters of denial based on
such things as 'not medically necessary' for clients who have been
getting [diabetic shoes and inserts] for years and years … We
have denials based on 'not receiving' doctors' notes in a timely
fashion, yet we have proof of delivery from the United States
Postal Service. We have doctors' chart notes returned to our office
because they were not stapled correctly.
"Denials for 'not medically necessary' seem to be popular, yet
the doctors' chart notes we submitted clearly indicate 'medically
necessary.' This requires us to send [the claim] back to
redetermination and wait another 90 days for payment on top of the
90 days it took to receive the initial denial. On and on it
goes.
"Our small company is compliant with every regulation out there.
Six months of providing products only to be denied payment is
bringing us closer to bankruptcy …
"Here is the interesting part of all this. I personally emailed
HHSTips 24 months ago regarding what I considered to be a
fraudulent DME provider. An investigator interviewed both myself
and my wife regarding this fraudulent organization. The
investigator sat in my dining room for the better part of Dec. 31,
2009, taking notes and asking questions.
"My small DME is in the throes of a ZPIC, and the company that I
emailed HHSTips about is still in business (they have billed $15
million dollars worth). And we are being told these audits are to
catch fraud. Something needs to be done."
Ninety letters on one day? Not stapled correctly? Come on,
now.
Clearly, something must be done to stop fraud. But what's being
done to small providers like these is creating a whole other kind
of Medicare nightmare.
