ARLINGTON, Va.--In a proactive move to provide CMS and federal legislators alike with concrete strategies for stemming fraud and abuse in the home medical equipment industry, the American Association for Homecare is crafting a plan that could be presented by the end of the year.
Among its possible components are increased scrutiny of new HME providers, real–time claims analysis, accreditation and unannounced site visits.
“We are still in the formative stages of this proposal, and we are working with our members to collect best practices,” Walt Gorski, vice president of government affairs for AAHomecare, said last week. “HME providers, we believe, are the most effective at determining these policies, since they are on the ground and know what works, what is a hassle factor and what doesn’t work.”
Already, AAHomecare has, in the last year, offered input on two separate anti-fraud efforts, including the proposed implementation of a surety bond requirement for providers and the draft of the Seniors and Taxpayers Obligation Protection Act of 2008 (S. 3164), or STOP Act. The latter requires the Secretary of Health and Human Services to change the identifier used to identify Medicare beneficiaries under the program.
The need for the industry to step forward with an anti-fraud plan has, however, become increasingly obvious in the face of derogatory reports that are appearing with alarming frequency in mainstream media such as the Wall Street Journal and the New York Times, Gorski and others said.
“The industry cannot leave its future in the hands of others,” said Gorski. “Recent reports highlighting improper behavior on the DMEPOS benefit validate much of what the HME community has been saying for a very long time: CMS has not adequately policed the program and kept criminals from getting supplier numbers.
“Under no circumstance should Medicare provide a supplier number to a broom closet that includes a bucket of sand and a wrench,” he stated, referring to a government sweep that found hundreds of alleged providers in South Florida and elsewhere had given fraudulent addresses to Medicare. (See HomeCare Monday, July 9, 2007.)
Industry stakeholders roundly applauded the idea of the proposal, which will seek to stop fraud at the front end of the payment process rather than relying on the current “pay-and-chase” system, AAHomecare officials said.
“It’s the realization that, as an industry, we have to be proactive rather than reactive,” said John Gallagher, vice president of government relations for Waterloo, Iowa-based VGM Group. “The drumbeat [of legislators] is that ‘you in the industry have to come up with concrete steps to fight fraud in the industry. If you don’t, we’re going to do it for you, and you don’t want that.’”
The proposal is something that “we could take to the Hill, but immediately, we could take it to CMS,” said Cara Bachenheimer, senior vice president of government relations for Invacare, Elyria, Ohio.
If the industry is to gain more credibility in Washington, “we have to somehow stem this tide of fraud and abuse that is happening,” Bachenheimer noted. “We need to take a slightly different tack in Washington. We can’t be up there blaming CMS. That doesn’t gain us any traction with the policymakers. The industry needs to elevate itself, take a more responsible role in addressing the problem.”
Coming up with anti-fraud measures that are both internal--that is, coming from within the industry--and external, such as actions CMS should take, will help, she believes.
“It’s good these discussions are going on, a good time to have them,” said Seth Johnson, vice president for government affairs for Pride Mobility Products, Exeter, Pa. It is unlikely that there will be any further legislation pertinent to HME this year, he said, but the industry must be braced for a new Congress, a new administration and new CMS leaders who will come on board next year.
“We need to bring the industry together, get what the framework would look like and, once there is agreement on the principles or provisions, then begin selling that in discussions [with legislators and regulators] to advance that proposal, “ he said.
Johnson also believes the plan will allow the HME industry to have a say in its fate. “They really do want to focus on addressing this [fraud-and-abuse] problem,” he said about the nation’s lawmakers. “We really have an obligation as an industry to provide them with what we’d like to see, and if we don’t do that, they are going to do something on their own. It’s better to be very intimately involved in the process.”
While specifics of the plan have not yet been decided, there are some general concepts that will likely make the final proposal. It is, for example, probable that several points will target “the most vulnerable area of the DMEPOS benefit, which is predominately new suppliers,” Gorski said. “In essence, how do you better validate that a supplier seeking a supplier number is a real provider?”
The answer, he said, could lie in real-time data, unannounced site visits and audits for an initial amount of time to ensure that the entity is serving Medicare beneficiaries and providing services for which they are billing
“That is an initial first step that we think is necessary toward improving the image of the HME community,” Gorski said.
Accreditation is another fraud-and-abuse-fighter, he said, because it helps monitor the monitors. “The National Supplier Clearinghouse is supposed to do a site visit for each new provider and upon re-enrollment every three years, but it appears that is not taking place,” Gorski said. “Accreditation is a way to double-check that CMS is policing its [monitors].”
Gallagher said some stakeholders, himself included, champion establishing an HME licensure board so the industry can police itself much the way physicians and pharmacists do.
”Right now, policing is not being done. If you know of fraud in your area, you turn it in and nothing happens. The industry has been screaming for years, ‘What are you doing, CMS’? and years and millions of dollars later, CMS wakes up and says, ‘Oh, you fraudulent providers.’ Let’s wrestle that away from them and let us be like the docs and pharmacists and police our own.”
There has also been talk of establishing escalating penalties with a “third-time-you’re-out” rule for providers who skirt the rules, and surety bonds for new suppliers.
“But we have to come to a consensus,” said Gallagher, who would like to fast-track the process so the industry can start selling the plan to legislators and regulators.
“Most likely the legislation will be in draft form this year for introduction in a new Congress next year,” said Gorski, who added that he welcomes any ideas on rooting out fraud and abuse. He can be contacted at waltg@aahomecare.org.