Facing Fraud in the US

  This past July, I was bouncing along a road on a crowded bus outside Port-au-Prince, Haiti, one evening en route to work at the LiveBeyond compound in Thomazeau — a region that’s about a two-hour drive from the Haitian capital. (Visit www.livebeyond.org/haiti-base.html.) My lifelong friends Dr. and Mrs. David Vanderpool had moved to Haiti permanently and were in the process of turning the 62 acres of land they’d purchased into a hospital, school, orphanage, and demonstration farm. The small hospital is now finished and provides a welcome change from the open-air concrete slab where, for several years, volunteers have provided care to 500 patients per week. Their programs have reduced infant mortality in the region by nearly 70% and have wiped out cholera in the area by purifying 50,000 gallons of water per month. All of this work has been done on a shoestring budget with only private donations.

  So, there I was on the bus, and I was mad. I mean really, really mad. I was upset because we were driving past a very large, unfinished, completely empty housing compound illuminated by floodlights that stood bigger than those used at most professional football stadiums, even though the compound had been abandoned. This huge construction debacle represents millions of dollars of wasted money from the Clinton Foundation in Haiti. Sadly, it is not a unique situation. The United Nations estimates Haiti has received $3.6 billion in aid since the 2010 earthquake. However, more than half a million people remain homeless in hundreds of informal camps, one of which was literally located across the road from this abandoned, unfinished housing project we were driving past. If LiveBeyond had only the money that had been spent on the nighttime outdoor lighting bills for the abandoned Clinton housing project, those involved could finish the orphanage, complete the vocational school, buy a bus to transport patients to the hospital, plant all the acreage on the farm, and still have money left over. In a country where so much work needs to be done, it is a crime that we can’t get money into the hands of responsible people who are changing lives. I can think of few things as healthcare providers that make us angrier than actions related to fraud and abuse, particularly when it affects the welfare of vulnerable people.

  Here is the problem: Not all the money donated to Haitian relief has been squandered. It just seems that way because the gigantic, unfinished boondoggle of a housing complex on the outskirts of Port-au-Prince that sits just a few yards from a refugee camp made out of cardboard and corrugated tin is so noticeable that it has become the “face” of incompetent relief efforts to the local population.

  The US government may do a much better job fighting fraud at home than it does overseas. Using new authorities created by the Affordable Care Act to clamp down on Medicare fraud, on Dec. 5 the Centers for Medicare & Medicaid Services (CMS) announced new rules designed to remove providers with “patterns or practices of abusive billing.” CMS estimates these changes will save Medicare more than $327 million annually. Some 25,000 providers have been permanently removed from Medicare roles. CMS has also used “predictive analytics” technology known as the Fraud Prevention System to identify providers and suppliers with suspicious billing practices — preventing $81 million in Medicare claims from even being paid in the first place. The changes CMS has announced allow it to deny enrollment to providers, suppliers, and owners of companies affiliated with any entity that has unpaid Medicare debt; deny or revoke the enrollment of a provider or supplier if a managing employee has been convicted of a felony offense that CMS determines to be detrimental to Medicare beneficiaries; and revoke enrollments of providers and suppliers engaging in abuse of billing privileges by demonstrating a pattern or practice of billing for services that does not meet Medicare requirements.

  The administration of hyperbaric oxygen therapy (HBOT) as a way to heal wounds in the US has similarly raised the eyebrows of those asking, “Where is all this money going?” As a past president of the Undersea and Hyperbaric Medical Society, I understand better than most the long history of HBOT coverage under Medicare. I understand how difficult it can be to get some patients the care they need due to the “sausage making” that takes place within Medicare coverage policy. However, inappropriate use of HBOT (treating patients who don’t need HBOT or can’t be helped by it, or providing more treatments than necessary) has brought the forces of the federal government down upon the entire industry. In other words, it’s the bad things that people notice and remember. Now all of us have to deal with the reality that HBOT is under a more watchful eye and that reimbursement and patient care may be affected by the scrutiny caused by those who tried to game the system.

  As an official with the Office of the Inspector General told the late Dr. Bob Warriner and me more than seven years ago, “If you can’t clean up your industry, then someone else will do it for you.”

  Today’s Wound Clinic will continue to monitor and discuss this new reality for outpatient wound clinic at length in 2015, beginning with the article “Lessons to Learn From Federal Indictments & Convictions Regarding HBOT Fraud” by Phi-Nga Jeannie Le, MD, on page 27 of this issue.