Preventing Medicare Fraud and Abuse

Recently, the Centers for Medicare and Medicaid Services announced a 10-point plan targeting Medicare fraud and abuse in the power mobility sector. The impetus for this aggressive crackdown was a Houston-based wheelchair scam involving unscrupulous doctors and providers who billed Medicare for power wheelchairs that were either never delivered or substituted with a less expensive model.

The scam cost taxpayers millions of dollars, and AAHomecare and durable medical equipment providers applauded CMS for taking action to prevent this type of fraudulent activity from occurring in the future. But, because the new CMS initiative is untested, we need to be diligent in alerting CMS to our concerns and monitoring the effect that it has on the vast majority of law-abiding DME providers and the patients they serve.

Three Main Concerns

AAHomecare has three main concerns about the CMS initiative. First, there is strong possibility that patient access will be jeopardized, which will be especially harmful for those patients with the greatest need.

The K0011 code, with its wide range of products, serves a diverse range of patients — from a COPD or arthritic patient who needs the most basic of power wheelchairs to a quadriplegic patient who depends on a sophisticated product that has special seating, tilt-in-space, etc. Stricter enforcement of the K0011 code could delay or deny access to a whole range of patients.

Second, we're concerned that CMS has not fully defined the moratorium on provider numbers. Will the moratorium apply to acquisitions and new branch locations? If CMS denies a provider number for an acquisition, how will that provider continue to serve the already existing Medicare population in their community? While CMS has indicated that they understand some of our concerns, the parameters of the moratorium are still not clear.

And, finally, the possibility of the use of inherent reasonableness (IR) is very troubling. Reducing the profit that unscrupulous providers are making off the government by 15 percent is unlikely to be a deterrent — whether they're pocketing $100 or $85, it's still free money.