Is this how CMS should fight Medicare fraud?


Let's face it, if everyone who deserved a traffic ticket actually got one, state and local governments would be rolling in the dough. Just about everyone speeds past red lights at the last minute, makes illegal u-turns or pushes past the speed limit when the highway's open. 

The truth is, though, we usually don't get docked for these things. Why? Well, I'd argue that largely, police leaders and governments know that it's a bad use of scarce resources to crack down hard on people committing minor infractions that haven't caused major harm and could easily have been a mistake. That means that officers are free to pursue truly reckless drivers who might kill someone.

Now, imagine that cops were paid on commission for every traffic ticket they handed out. How would the picture change? Well, you can be sure that they'd rack up countless tickets for minor infractions--which are, I'd imagine, far more common than spectacular flame-outs. And most people who got the tickets would end up paying them, as they wouldn't have the resources to fight. Meanwhile, police officers might very well end up letting drunken speeders pass by at 120 mph as they wrote the ticket for the mom who crossed lanes without signaling.

I was reminded of this principle--that hunting for bad guys seems to work better when the government gives good people a reasonable amount of slack--when I read the story of a Tennessee medical practice that went through 18 months of arguments, three levels of appeals and $150,000 in legal fees over what sounds like a rather petty series of arguments over small Medicare billing issues. Contractor AdvanceMedCorp., which showed up unannounced to review a sample of claims, originally told the doctors at Premier Medical Group that they owed Medicare $1.6 million, based on its extrapolation from claims on which Premier allegedly was overpaid by $7,500. Not only did Premier execs have to go through a year and a half of hell to prove they were on the level (in many cases because of issues relating to very small documentation problems), they had Medicare payments withheld for eight months.

Clearly, what we have here is traffic cop scenario two, which doesn't work for anyone, including CMS. Just as the cop who writes little tickets misses the hot-dogger speeders, the drunks and the downright reckless, CMS auditors who receive incentives to bear down on even smallest of violations have that much less time to capture the true crooks.

Is this how CMS should fight Medicare fraud? Not if it truly wants to find thieves and liars. (The fact that it's still missing paying out 14 percent to scammers, by its own estimate, suggests that something isn't right.) But if it wants to make a mess out of the lives and practices of average providers, well, it's definitely making progress. - Anne

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