‘Groundhog Day’ for Medicare Audits?

WASHINGTON — President Obama’s plan to hunt down perpetrators of Medicare fraud with “high-tech bounty hunters” is likely to create problems for legitimate providers and doesn’t address the real problem — keeping the bad actors out of the system in the first place, Walt Gorski said on Friday.

“We were a little disappointed in the president’s remarks related to fraud and abuse. We think that the bounty hunter idea, if not structured properly, is going to pose serious issues for home care providers,” said Gorski, vice president of government relations for the American Association for Homecare.

Last week, the president issued a memorandum calling on executive departments and agencies to step up efforts to recapture improper payments by pairing highly skilled accounting specialists and fraud examiners with state-of-the-art technology to identify suspicious claims patterns. The bounty hunter techies’ pay would be tied to whatever they recouped.

And therein lies a big problem, according to Gorski. “The incentive is for the bounty hunter to review as many claims as possible and unduly burden providers or trip them up with technicalities,” he said.

Many HME providers are already complaining that they are being inundated with requests from Medicare’s RAC, CERT and ZPIC audit contractors for further documentation that, in some cases, can reach 50 pages per claim (see ZPIC Audits Cripple Miami Provider).

Gorski said he is concerned providers could find themselves trying to address frivolous requests that drain business resources.

“The bounty hunter should be held accountable if their requests are frivolous,” he said. “The provider has to put all that time and energy into developing the information the government wants. This should be a two-way street if that’s the direction.”

Audit Déjà Vu

In his memo, the president said he was supporting a bill — the Improper Payments Elimination and Recovery Act (S. 1508), introduced by Sen. Thomas R. Carper, D-Del. — that would require all government agencies to shell out more than $1 million on recovery audits for their programs.

But Richard P. Kusserow, president of Strategic Management Systems in Alexandria, Va., and the former Department of Health and Human Services Inspector General from 1981-1992, cautioned that, because of the expanding RAC program, providers could soon find themselves in a “Groundhog Day” scenario.

Like Bill Murray, who plays a weatherman living the same day over and over in the 1993 film, providers could be audited by multiple contractors for the same claims, Kusserow told those attending the National Medicare RAC Summit on March 4. A RAC auditor could refer a case to a ZPIC contractor who, in turn, could send the case on to the OIG.

“Ideally,” said Gorski, “we think the better approach would be to not allow the bad guys to get in to begin with. We wouldn’t have all this ‘pay-and-chase’ if the government would root out the bad guys before they get in … Until you crack down on letting these people in to begin with, we will continue to have a fraud problem.”

Gorski said AAHomecare, which has proposed a 13-point plan designed to curb fraud and abuse, is hoping to assist regulators in devising effective policies that would not only help to stop fraud but also restore HME providers’ reputation.

“We hope to work with CMS to develop those policies,” Gorski said, adding that until fraudulent HME providers are eliminated, the sector will be seen as crooked.