CMA Health Policy Blog

Getting the Right Bad Guys For Defrauding Medicare

February 29, 2012 at 8:51 pm meshepard Leave a comment

Yesterday the U.S. Department of Justice indicted a Texas doctor and six others for defrauding Medicare and Medicaid of $375 million. The doctor ordered home health care services that were unnecessary and never even delivered to Medicare beneficiaries. We agree that’s outrageous.

Catching these criminals is good news for the federal government, taxpayers, and Medicare beneficiaries – such massive fraud is exactly the type of waste in Medicare that needs to stop.

However, as good as this news is for Medicare, we have to ask: how does Medicare pay out hundreds of millions in fraudulent home health claims over half a decade, while denying home health coverage for our 80-year-old client in Maine with paraplegia?

Ms. M’s doctors ordered skilled nursing for wound care and physical therapy to maintain her ability to use her wheelchair in her home. She has a legitimate need for home health services, but the only home health agency in her area claims the Medicare agency will charge it with fraud if it bills Medicare, because she won’t improve. This goes directly against the Medicare regulations, which allow for services designed to maintain her level of function.  Unfortunately this “Improvement Standard” is so ingrained in Medicare contractors and providers, that providers fear being accused of fraud if they bill for these legitimate services.

We are buoyed by the successful investigation by law enforcement in the Texas case. Such victories should leave more money for people like our client, who have legitimate home health needs that are coverable by Medicare.

Entry filed under: Improvement.