CMS priorities may not be in the right place


So, CMS got lacerated by the HHS Office of the Inspector General last week, which accused the agency of misrepresenting its ability to cut fraud.

CMS had said that in 2006, that it had managed to cut Medicare fraud by billions, a feat that justifiably won it kudos on the Hill. Then, the cheering stopped and HHS took a closer look at the results. The OIG wasn't pleased with what it saw. Apparently, Medicare officials may have played fast and loose when it came to calculating the level of fraud actually going on, and avoided taking steps that would have pushed up the calculations of fraud to much greater heights. By the OIG's projections, Medicare officials missed more than one-third of improper spending for some durable medical goods during fiscal 2006, in part because it simply refused to take standard steps like comparing invoices submitted by salespeople against physician records. (Strangely enough, invoices that aren't backed by doctors' orders probably aren't kosher.)

Clearly, as we've reported before, DME is a huge and festering source of fraud, a drain on the program which, after one billion and another and another, adds up to some real money. CMS is clearly trying to get at this source of fraud, by instituting a new program that will help it avoid paying for equipment ordered by dead doctors. And hey, if nobody dead is ordering wheelchairs, you are getting somewhere, right? (Well, just barely.)

Now, compare the huge reservoir of fraud yet to be found here to those providers being audited by the Recovery Audit Contractor program, a fraud- and overbilling-prevention program that, as many of you might have noticed, looks like a nasty, punitive harassment program to this editor.

Let me get this straight: CMS has billions of dollars in fraud yet to be discovered--on purpose, from what it seems--and some easy ways to get back billions by simply using the tool it already has. Instead, it mounted an entire program designed largely, from this spectator's eyes, to instill fear in a provider population that isn't that thrilled with accepting its rates away. Can't say I understand how this works.

How about you folks? Do you think there's any excuse for CMS not to focus on the more-fertile area of DME fraud and other low-hanging fruit? Or does the RAC program have some hidden virtues I haven't yet detected. - Anne

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