Do AOs police fraud?

YARMOUTH, Maine - Accreditation organizations help to prevent and eliminate fraud, waste and abuse in the Medicare program, but it's not their main job, they say.

After news broke earlier this year of “Operation Brace Yourself,” a $1.2 billion fraud scheme involving medical unnecessary braces, HME providers shook their heads wondering, “How are they accredited?” The scheme involved illegal kickbacks and bribes by HME providers in exchange for referrals of beneficiaries by medical professionals working with fraudulent lead-generation companies.

“We're not the fraud police; we're the quality police,” said Sandra Canally, founder and president of The Compliance Team. “Our focus is on quality patient care; it's not on a forensic audit of their billing.”

CMS has required that providers get accredited for more than a decade. It's a process that, generally, involves meeting quality standards around business (administration, financial management, HR management, consumer services, performance management, product safety and information management) and service (intake, delivery and setup, training and instruction, and follow-up).

Of course, in the process of determining whether or not a provider meets these standards, AOs can uncover fraud.

“Typically, it stems from patient complaints,” she said. “Then you can deny or revoke accreditation based on a pattern of unresolved patient complaints, and we have done that.”

One such scenario that might raise a red flag: An AO might ask a provider to show them a prescription for a piece of equipment and the provider might say, “We got it from a lead-generation company,” which is legal, but the AO might subsequently find out from patient complaints that the equipment wasn't wanted and there's no process for returning it.

“That's a violation of the standards,” said Tim Safley, program director of DMEPOS, sleep and pharmacy for ACHC, “and we'd report it.”

AOs also conduct on-site surveys every three years, but in “Operation Brace Yourself,” like in other fraud schemes, companies that want to run afoul of the law will find “workarounds.” They might, for example, buy a provider with a Medicare number—one that may not have to renew their accreditation for another few years—and then change its business model.

“They're aware and they'll find the little niches,” Safley said.

AOs will always investigate when they see patterns that may be troubling or suspicious—Canally calls it “pulling the thread”—but it's not their job to bring up what they may suspect as fraud with a provider.

“We report it to CMS so it can be reported to the Office of Inspector General,” she said. “Then it's up to them to take action. It's not our jurisdiction.”