Editor's Note:

We’re Not in This Alone

CMS is overstepping — to HME’s benefit.

• By David Kopf
• Jun 22, 2011

It’s not hard to feel isolated and singled-out when it comes to living under CMS’s bad public policy management. This is especially true when it comes to CMS’s ramp up of pre- and post-payment audits of Medicare claims for DME. As we outlined in our June issue’s cover story, “The Dam Has Burst,” the agency’s audit-palooza is putting many providers into exceedingly dire financial positions, but, at least in the case of many post-payment audits, those audits are often overturned at appeal.

It’s enough to make you think you’re on “Candid Camera” and everyone else is in on the gag. CMS hires third-party auditing firms to second-guess both HMEs and their referral partners regarding the medical necessity of various types of DME and related services. These are firms with all the accounting and database expertise in the world, but not much in the way of medical training.

While no one wants the taxpayers charged for bad claims, given the high degree of success providers are having at appeal, one has to wonder whether CMS’s overzealous audit campaign has to do with preventing actual fraud or simply trying to cull the number of providers by strangling their cash-flow to a trickle.

The whole situation seems like a scene cut from the movie “Brazil,” which is about a bureaucratic dystopia so out of touch with reality it is quite simply surreal. Is no one besides the HME industry noticing how cuckoo this is?

Well, it turns out we might not be the CMS castaways we thought we were. While we know physicians and hospital claims are being audited, CMS, with the aid of its trusty assistant, the Health and Human Services Office of Inspector General, is now setting its sights on a whole new group: the mental healthcare industry.

Specifically, the HHS OIG recently released a report, “Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents,” which alleges that psychiatrists are mis-prescribing anti-psychotics to agitated Alzheimer’s and elderly dementia patients. The report was full of statistics that basically made it appear that the practice was scandalous and life threatening, and proposed a solution: audit the medical necessity of psychiatrists’ prescriptions. HHS OIG Inspector General Daniel Levinson then went on the road to publicize the report in high-profile venues such as CNN.

Does this pattern sound familiar? It should: the HHS OIG releases reports claiming fraud and unethical practices in a given healthcare sector to make its case, and then starts waving its audit cudgel in the air. Fortunately, psychiatrists seem to be hip to the fact that the report is the misdirection in CMS’s latest bureaucratic slight of hand. The real issue is that the anti-psychotics psychiatrists prescribe to prevent agitated Alzheimer’s patients from hurting themselves (by ripping out IV tubes, etc.) are expensive.

Fortunately, Dr. Daniel Carlat, M.D., the Associate Clinical Professor of Psychiatry for Tufts University School of Medicine, and the publisher of The Carlat Psychiatry Report (www.TheCarlatReport.com) fired back at Levinson in a CNN column of his own: “The solution is to expand research on safer and more effective treatments of dementia,” he writes. “It is not, as proposed by Levinson, to hire government auditors to decide whether doctors are prescribing drugs ‘appropriately.’ God help us if they do.”

While I shudder to think of CMS getting so caught up in a hog-wild auditing frenzy that it would start auditing any and every type of claim, I do see this as a possible political foothold for HME.

Specifically, it’s one thing for CMS to over zealously pursue HME and doctors. HME is small and the public isn’t aware of our plight, and hospitals are somewhat faceless.

But when CMS cries “havoc” and lets slip its auditor hounds to make existence even more awful for patients suffering truly terrible final days, it humanizes the issue while raising the ire of the American Psychiatric Association. Hopefully this will give us another much-needed ally in shining a spotlight on an out-of-control CMS.

This article originally appeared in the July 2011 issue of HME Business.