Medicare drops fraud ball

Saturday, August 31, 2002

In reply to your article in the June issue of HME News, "Let's raise industry standards," you stated that "the FBI believes one out of 10 DMEPOS providers is a crook." I work as a manufacturer's rep in the Los Angeles area and believe the number is closer to three out of 10 at least. In my territory, approximately 25% of the providers are committing some form of Medicare fraud.

I have called Medicare regarding providers that are clearly committing fraud and six months later, nothing has happened. (In fact, the provider is doing more business than ever.) A provider was given to Medicare on a silver platter and nothing happened. As manufacturer representatives, unless you are deaf and blind, you know who is billing fraudulently but are still, although reluctantly, required to service them.

In short, all of the Medicare fraud hotlines do not mean anything if they are never followed through.

— Anonymous

Editor's note: HME News rarely runs anonymous letters, but, upon verification of this writer, agreed to do so in this case.

Where's data?
I just finished reading your article titled "Who fleeced
who" in HME News (July 15). It was an article that answered questions my boss and I have been asking each other. We wondered why AA Homecare has not come out with this type of data for all the codes that were included in the recent OIG report. If our industry had this type of data to share with our representatives, it would be a powerful tool. Is there any chance that you have a journalist that is digging through this data for the other codes?

— Ron Drees is sales manager of St. Rita's Homecare in Lima, Ohio.

In the home & homebound
There is a significant piece of misinformation in the article "Consumers Storm Capitol Hill," and I believe it is imperative to correct it.

The article indicates (through quotes mostly) that if a consumer leaves their home using a piece of DME that has been paid for by Medicare they will lose their benefit. This is categorically incorrect. While Medicare only reimburses for DME that is medically necessary for use in the home, nothing prevents a consumer from using the equipment outside the home.

I believe there are several reasons for this confusion. First, there are two issues where the industry is currently pursuing legislative or regulatory change. One is referred to as the "homebound" issue. This issue relates to home health services. In order to qualify for home health services, a Medicare beneficiary must be considered homebound. A committed and determined individual by the name of David Jayne started a coalition to change the definition of "homebound" after losing his home health benefits because he left his home. The absences from his home caused him to fall outside of the extremely restrictive Medicare definition of "homebound".

The second one, referred to as the "in the home" issue, has been lead by Sunrise Medical through the formation of the Coalition to Promote Independence for People with Disabilities. The Coalition is seeking a regulatory change to the interpretation of "for use in the home". The issue is that Medicare will only pay for equipment that is necessary for use in the home. The language has been interpreted to mean literally within the four walls of the home structure. An example of the impact would be: if a consumer needs a power wheelchair in order to return to work or school, participate in their community, be involved with family and friends, take their children to school and the myriad activities of independent, integrated living, they may not get it. They will only receive (paid for by Medicare) what they need to get from point A to point B inside their home. That may mean they receive a significantly less appropriate piece of equipment (e.g. a manual wheelchair). This type of coverage policy prevents people with disabilities from being independent and from being involved in their communities. It can literally confine a person with a disability to their home. However, nowhere in the Medicare policy does it state that if they leave their home they will lose their benefit.

The legislative conference sponsored by AAHomecare involved consumers for the first time. It was a tremendous advancement in connecting suppliers and manufacturers with the people that we serve, the people that are ultimately most impacted by the decisions Congress makes regarding healthcare. Consumers understand, better than anyone else, how policy decisions impact their lives. However, the industry has a responsibility to educate consumers regarding policy. Having consumers "storm Congress", as the article's title suggests, with incorrect information, lessens the consumer's credibility and the credibility of our industry as we attempt to influence policymaking.

— Rita Hostak is Vice President of Government Relations of Sunrise Medical