Preventing Medicare Fraud and Abuse

Recently, the Centers for Medicare and Medicaid Services announced a 10-point plan targeting Medicare fraud and abuse in the power mobility sector. The impetus for this aggressive crackdown was a Houston-based wheelchair scam involving unscrupulous doctors and providers who billed Medicare for power wheelchairs that were either never delivered or substituted with a less expensive model.

The scam cost taxpayers millions of dollars, and AAHomecare and durable medical equipment providers applauded CMS for taking action to prevent this type of fraudulent activity from occurring in the future. But, because the new CMS initiative is untested, we need to be diligent in alerting CMS to our concerns and monitoring the effect that it has on the vast majority of law-abiding DME providers and the patients they serve.

Three Main Concerns

AAHomecare has three main concerns about the CMS initiative. First, there is strong possibility that patient access will be jeopardized, which will be especially harmful for those patients with the greatest need.

The K0011 code, with its wide range of products, serves a diverse range of patients — from a COPD or arthritic patient who needs the most basic of power wheelchairs to a quadriplegic patient who depends on a sophisticated product that has special seating, tilt-in-space, etc. Stricter enforcement of the K0011 code could delay or deny access to a whole range of patients.

Second, we’re concerned that CMS has not fully defined the moratorium on provider numbers. Will the moratorium apply to acquisitions and new branch locations? If CMS denies a provider number for an acquisition, how will that provider continue to serve the already existing Medicare population in their community? While CMS has indicated that they understand some of our concerns, the parameters of the moratorium are still not clear.

And, finally, the possibility of the use of inherent reasonableness (IR) is very troubling. Reducing the profit that unscrupulous providers are making off the government by 15 percent is unlikely to be a deterrent — whether they’re pocketing $100 or $85, it’s still free money.

For the past year, AAHomecare has been discussing with CMS ways to control costs in the power mobility sector and better fit the technology with patients. We’ve submitted new codes for the products now covered under the K0011 code that would characterize wheelchairs by clinical indicators and the technology available. By doing this, CMS would have a better indication of where fraud and abuse is occurring. With this information, CMS could target fraud and abuse with a more focused approach, rather than painting all providers with a broad brush stroke.

We’ve also recommended the use of medical necessity documentation that would give providers clear guidelines on the documentation necessary to support a Medicare claim for a power wheelchair. In addition, AAHomecare is developing a Medicare fraud and abuse pamphlet for physicians and beneficiaries that would lay out the rules regarding Medicare payment for mobility equipment.

A Proactive Approach

What overall impact will CMS’ 10-point initiative have on DME providers? That could depend on whether CMS implements more safeguards on power wheelchair utilization, such as modifying coverage criteria, increasing audits and site visits, or more strictly scrutinizing claims and new suppliers. It could also depend on the actions that we take as an industry.

In the final analysis, it’s clear that the home care community must continue to take a proactive approach to this issue. Whether it’s publishing a pamphlet for physicians and patients or making clinical assessments a routine business practice, we must show CMS, and the general public, that legitimate DME providers are part of the solution and not the problem.

Now is the time for good providers to stand up against the bad and reclaim their reputation and their business.

Kay Cox is president and CEO of the American Association for Homecare, Alexandria, Va. For more information about AAHomecare, visit www.aahomecare.org, or call 703/836 – 6263.