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Former Medical Director Speaks Out About Medicare Fraud
Date:2/11/2009

oval process rarely allows companies to be caught or penalized if they misrepresent their products.

Funding of fraud detection has always proven to be a good investment. Medicare's policies are based on belief in the basic honesty of suppliers and providers. That philosophy has been an easy target from its inception, but now the stakes are too high and the need too great to allow criminals and unscrupulous suppliers to bilk the system. Better coordination between CMS and the FDA will also enhance Medicare's ability to stop paying for products the FDA deems to be unsafe and a risk to patients (i.e. certain brands of electric heating pads). Presently there is no communication between CMS and the FDA regarding product safety issues.

Another solution is a robust HCPCS coding system which accurately defines products and services. Pricing, policies and coverage can be more precisely based on accurate coding. At present, a surprising number of codes for services and equipment are vague, making them prime targets for fraud and abuse. Frequently a code created for good quality FDA regulated equipment becomes filled with low quality goods. Unfortunately the problem is usually not caught until beneficiaries are harmed or auditors notice dramatic spikes in code utilization. Even then the abusive practice can be difficult to stop because the poorly defined code may technically allow the inferior products to use that code. All of this highlights the need for a combined approach with better policies, better code descriptions and strict enforcement on the front end of all Medicare approvals.

Doctor Edwards is a Medicare consultant assisting companies with all aspects of government relations including clinical and technical issues. He can be reached at Advanced Healthcare Consulting, 9353 Two Notch Rd., Suite B, Columbia, SC 29223. Ph 803.865.9225, E-mail

SOURCE Advanced Healthcare Consulting
Copyright©2009 PR Newswire.
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