Saturday, August 31, 2002

Providers: Give us a break
Q: Is CMS still encouraging patients to report us to the Fraud Hotline or the DMERCs for every alleged billing mistake? Why doesn't CMS give us a break?

A: They have. CMS has just issued a memorandum which states that patients will no longer be encouraged to squeal to the government about alleged billing "inconsistencies." Instead, beneficiaries are directed to "compare the services" they received with those that appear on their Medicare Summary Notice. If the beneficiary has questions, he/she is directed to contact the provider, not the government. The beneficiary will be advised to contact the DMERC only after the beneficiary first speaks with the provider and still believes "further investigation is needed due to possible fraud or abuse."

This is a significant change in policy. When CMS tells your beneficiaries to call its Fraud Hotline or report to their DMERC whenever they perceive alleged "billing inconsistencies," you are tainted with two incorrect messages. First, billing inconsistencies rarely constitute fraud. Many DME suppliers have been put under the federal microscope unfairly because of inaccurate or exaggerated accusations. Second, the best way to identify and resolve billing inconsistencies is usually by prompt, frank dialogue between the concerned patient and you. Errors may be caught quicker and easier. Patients can be educated about misunderstandings. Systemic problems can be flagged early enough for meaningful correction — before the feds get involved.

Key advice: It is essential for your compliance program to make it easy for beneficiaries to have productive conversations about billing questions. Verify that you have a clearly-communicated mechanism for patients to report problems, for problems to be investigated and resolved, for the patient to feel respected, and for oversight to monitor ongoing compliance.

Neil Caesar is president of the Health Law Center in Greenville, SC. Reach him at or