Industry Voices—We need to fight fraud the right way

A new study published in the Journal of the American Medical Association (JAMA) found that as much as 25% of America’s spending on healthcare is wasteful. This translates into an estimated $760 billion to $935 billion wasted every year, more than the federal government spends on Medicare, health insurance subsidies and the Children’s Health Insurance Program combined.   

The U.S. already spends roughly $10,000 per American on health each year, and, with costs continuing to climb, it is critical that we do everything we can to prevent fraud, abuse and unnecessary spending.

But, while the federal government’s goal to curb wasteful spending is great in theory, the current approach is misguided in practice—especially when it comes to Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) like home oxygen supplies and equipment.

As the JAMA study suggests, there is a tremendous opportunity for the Centers for Medicare & Medicaid Services (CMS) to root out fraud—something the home oxygen industry supports wholeheartedly. The Council for Quality Respiratory Care recently submitted a comment letter (PDF) to CMS urging efforts that are “rational, balanced, and targeted to ensure that limited Medicare funds are directed at activities that appropriately need to be curtailed, rather than focused on technical errors or ‘magic’ words.”

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Under a recently proposed rule, all durable medical equipment suppliers and providers are required to furnish a face-to-face/written order prior to delivery. This means that suppliers, including home respiratory and sleep therapy suppliers, must have access to each patient’s medical record. The problem is that there is a tremendous burden on practitioners and suppliers who are forced to chase these documents. Moreover, because there is no standard requirement for the types of data that must be reported to CMS, suppliers have no choice but to guess what words the contractors will accept to establish the medical necessity data element in order to be reimbursed.

To be clear, doctors should always be involved when appropriately prescribing supplies for their patients. But this haphazard, expanded review has resulted in a substantial number of patient denials during audits, which are almost uniformly reversed and paid after months and years of appeals. All the while, too many patients are denied the home oxygen supplies and equipment their doctors believe they need. This is unacceptable. 

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While the industry supports streamlining the auditing process and agrees that medical practitioners must be involved in the ordering of medical supplies and equipment, suppliers remain concerned that the proposed DMEPOS rule is out of step with CMS’ Patients Over Paperwork Initiative and would likely create greater confusion among practitioners, suppliers and beneficiaries.

There is a better way.

In order to more effectively fight waste, streamline the oversight process and ensure that patients continue receiving timely care without delays, CMS should allow doctors to submit the standardized data elements CMS has published in its templates and the Certificate of Medical Necessity, both of which include all of the information needed to establish medical necessity without having to ask contractors to dig through medical records. By standardizing the data that need to be collected, CMS has an opportunity to significantly reduce the risk of clerical errors and paperwork issues that have often delayed patients from receiving the legitimate medical supplies they need. 

We couldn’t agree more with administration calls for (PDF) “flexibility in the enforcement of the face-to-face requirement, eliminating this overly burdensome requirement for most Medicare providers and beneficiaries.”

It is time to fight fraud and waste the right way: by reducing burdens on providers, streamlining the oversight process and finally putting patients over paperwork.

Dan Starck is chairman of the Council for Quality Respiratory Care, a coalition of the nation's leading home oxygen therapy provider and manufacturing companies.