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Medicare Expands its Crackdown on Fraud
By Julie Appleby, USA Today
October 7, 2008
Acting Medicare chief Kerry Weems on Monday announced new efforts to combat fraud in seven states, focusing on companies that improperly provide patients with medical equipment such as wheelchairs and oxygen supplies.
Some changes also target home health care agencies in Miami-Dade County. USA TODAY reported Monday that Medicare is on track to pay a projected $1.3 billion there this fiscal year for services to homebound patients — up 1,300% since 2003.
The broader measures are directed at states seen as at-risk for fraud: California, Florida, Illinois, Michigan, New York, North Carolina and Texas.
"There are many reputable, caring durable medical suppliers who do a very good job. But then there are also some that are, frankly, rotten," Weems says. "In targeted areas around the country, we're going to change our tactics."
Among the changes: more stringent background checks of equipment suppliers, unannounced visits to businesses and more scrutiny of billing records submitted by doctors. Investigators also will conduct more interviews with beneficiaries to see whether they receive their supplies — and if they qualify for such benefits.
The new measures come after several congressional reports have described questionable Medicare payments to medical providers nationwide.
"A lot of what they're saying is what they should be doing already," says Walter Gorski, vice president of government affairs for the American Association for Homecare, which represents medical equipment suppliers.
Weems also announced steps to battle a sharp rise in bills submitted by Miami home health care agencies, which send nurses and aides to assist homebound and disabled beneficiaries. Investigators will focus on agencies that claim to provide services to sicker-than-average patients, which qualifies them for special additional payments.
Those payments, called outliers, represented 60% of all home care bills paid by Medicare last year in Miami, compared with a 6% average nationwide, government data show.
Weems said Medicare will immediately suspend payments to the 10 Miami agencies that collect the most from the outlier program while a review is conducted. The agency also will cap outlier payments to all Miami agencies at no more than 5% of their total reimbursements.
The suspension "will probably put some agencies out of business, but that may not be a bad thing," says William Dombi, vice president for law at the National Association for Home Care & Hospice, the industry's trade group. "To be in that top 10 means they had to be very different than anyone else."
He also agrees with the Miami-specific cap of 5%.
"They should have done that a long time ago," he says.
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