This story from Tuesday's Miami Herald discusses the staggering amount of money Medicare spent treating diabetic home health patients in Miami in 2008. Turns out, more than half of the money Medicare spent on this type of care in 2008 was spent in Miami-Dade county. The article mentions that OIG suspects that this might be due to fraud in Miami-Dade county. (I am the only one whose response to that insight is "Of course it is!!"). OIG and DOJ have been reporting on and discussing the rampant fraud in Miami-Dade county for more than a year now and yet they seem to be surprised by these findings.
The article states that bribery seems to be the driving force behind the fraud. According to the story, some agencies in Miami-Dade were paying doctors $100 per referral. They were also paying patients between $700 and $1500 to use their Medicare numbers as well as offering televisions and groceries.
The article goes on to mention the new ten percent outlier cap. The agency they interview correctly points out that the outlier cap is not the way to solve the diabetes overpayment issue. This article makes clear what I have been saying for a long time - Miami-Dade county is an outlier. The diabetic overpayments were due to over criminal activity. A fact which becomes clearer and clearer with each new report out of Miami.
A provider that is willing to bribe individuals to use their provider number so that they can bill fraudulently, is not going to be deterred by the ten percent cap. Cap or not they are making money off of the fraud and it is 100% pure profit. The other measures - suspending payments to suspected fraudulent providers, HEAT task force, the revalidation efforts - are far more likely to reduce this type of activity. The real issue is preventing criminals from getting involved and then identifying fraudulent providers and prosecuting them. Part of this will include efforts by the industry to police itself. Providers will know when their competitors are paying physicians for referrals. (You know you will.) In these cases, providers need to turn in the fraudulent providers. (Or file a false claims action against them.)
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