What a convenient phrase. There is no doubt extraordinary situations that constitute Medicare Fraud. However, it is becoming clear that this catch-all, very political phrase is being used to both demonize legitimate and ethical Medicare providers as well as to provide an excuse to reduce Medicare benefits.
In a recent conversation about post-mastectomy benefits, I was faced with horror stories of beneficiaries being contacted about the silicone breast prostheses they had received and these same beneficiaries were told that, "if they really didn't need these prostheses, Medicare Auditors would find out" and "they would loose their benefits". This type of "cost re-coupment action" is classified as "waste, fraud & abuse investigations" and heralded in triumph by politicians and administrators alike as cost savings events. But are denial of services or re-coupment of payments for legitimately and appropriately provided services, a "cost savings"?
Another growing trend is of Medicare developing unpublished, internal policies that reduce the allowed quantities of medically necessary physician prescribed items based on "opinions" not based on medical necessity or published payment policy. Internal edits, external audits of varying degrees including RACs, ZPICs and others have fostered a "guilty until proved innocent" atmosphere within the CMS Medicare Program that has the very real potential to quietly reduce post-mastectomy benefits and services.
Comments