Fraud and Abuse

It has been more than 20 years that I have been railing about fraud and abuse in both the Medicare and Medicaid programs.

When my family relocated to Florida, I worked as a manufacturer’s rep. I covered the east coast of the state from Miami to Jacksonville. One of the lines I represented offered TENS units. But when I realized at that time how TENS were being used for fraud and abuse, I dropped the line; I did not want to be involved with any part of this scam.

Last month on NPR’s “Morning Edition” (Oct. 11), I heard legal affairs reporter Greg Allen give a report titled “Health Care Fraud Acute in South Florida.” Fraudulent Medicare claims estimated at between $300 million and $400 million were prosecuted in just two South Florida counties in the past year, Mr. Allen said. Estimates of total losses range as high as 10 times that much.

The total amount of Medicare fraud and abuse is beyond my ability to comprehend. Suffice it to say that mega-mega dollars are being taken out by the shovelful from the system.

I know hundreds of fine DME/HME providers throughout the United States. Our industry is blessed with many who truly provide products and service to their customers and patients. This is an industry in which providers care. They are concerned about the well-being of their clients, even when a great deal of what is provided to their patients is not reimbursable.

I have been involved in the health care industry since snake oil was sold on street corners as a panacea to cure all ailments. Our segment of the profession has come a very long way, and it should be looked upon and recognized for what it is — caring people who serve their community in the best ways they know.

This is an industry where honesty rules, and its good providers must be protected.

We have made a giant step forward in helping to control fraud by having providers earn accreditation to participate in competitive bidding, but that is not the answer either. I suggest licensure is the right route to take. A license can be revoked or suspended until the provider has proven the company is conforming to all the rules.

I recognize the fact that fraud and abuse will never be completely obliterated. There will always be a small number of providers who will be tempted to cheat. Deceit exists, and no matter which industry or profession, there will always be some swindlers who try to make extra bucks without earning them.

But can we reduce fraud and abuse by 90 percent? I think that with a licensure program and a sufficient number of inspectors to do the monitoring, it could work.

You can get a copy of Greg Allen’s report at www.npr.org. Please read it, because your livelihood depends on where and how the problem with Medicare fraud and abuse is resolved. AAHomecare and your state DME association should be your voice. Join and support them. Guide them, and stay in business.

Now, about competitive bidding, that is also not the way to save money. It is wrong to force providers to compete for participation in Medicare.

Scheduled reimbursements should never be based on the lowest-priced item, because then all we are doing is expanding business for low-cost companies and forcing excellent businesses that have high standards to fold.

Instead, I would like to see all providers compete with one another on service, quality and customer satisfaction. All HME providers should be able to provide the best merchandise instead of being forced to provide the least expensive items to their patients.

Under a system of free trade, Medicare beneficiaries would benefit, providers would remain solvent and the government would save more dollars than in it has estimated for its competitive bid.

Sheldon “Shelly” Prial is based in Melbourne, Fla., with Prial Consulting and also serves as the director of government relations for Atlanta-based Graham-Field Health Products. In 1987, he founded the Homecare Providers Co-Op, now part of The VGM Group. He can be reached by e-mail at [email protected] or by phone at 877/553-5127.