Two Brothers Plead Guilty to Wheelchair Fraud
Wheelchair fraud is in the news again, as two men in Texas pleaded guilty to submitting fraudulent claims to Medicare for power wheelchairs. In the past year, the Federal government has taken many steps to crack-down on power wheelchair fraud. In February 2004, the Deptartment of Justice announced 11 arrests in Texas as the result of Operation Roll Over. In September 2003, the Centers for Medicare and Medicaid Services (CMS) announced Operation Wheeler Dealer, a ten point plan to curb wheelchair fraud in the Medicare program. At the end of April 2004, CMS announced new payment guidelines to make sure that people who need wheelchairs get them and people who don’t, don’t.
But really, wheelchair fraud is not new. Scams like this have been around, as long as their have been power wheelchairs. For example, in 1997, the CEO of Motion Medical Inc. pleaded guilty to billing for wheelchairs when only three-wheeled scooters were provided.
So why is it in the news so much these days?
There are three main reasons:
- The losses reached a level hard to overlook.
- The tools for finding fraud are good at finding this kind of scam
- Like other businesses, fraud goes through cycles
Millions of dollars down the drain
“Medicare spending for power wheelchairs and power scooters has skyrocketed in recent years to more than $1.2 billion a year, yet some beneficiaries who really need these mobility devices are not getting high-quality and timely assistance,” Dr. McClellan in CMS Press Release. Big dollars get more attention. While this is still a small amount of money compared to total Medicare spending, rapid growth in an area that is known for being vulnerable for fraud gets attention.
Fraud Detection Tools Focus on Big Jumps
“In Harris County, Texas alone, Medicare paid for more than 31,000 power wheelchairs in 2002, compared to just over 3,000 power wheelchairs in 2001.” Sept 2003 DOJ Press Release Fraud detection tools are great at finding big jumps like that. You don’t need a particularly sophisticated tool to notice that you’re spending 10 times as much on wheelchairs as you were a year ago. A simple SQL query should find fraud that obvious.
When we notice a spike in fraud like this, we put lots of controls in place. There are new requirements for reviewing provider applications. Prior authorization is required more often. It doesn’t take long for the fraud to move from the current emergency to some new area that is getting less attention. After a few years, we start to wonder, “Why do we require prior authorization for this, when it is approved 99% of the time?” The controls seem to cost more that they are worth. Newer scams take priority and soon the old scams seem less important. We loosen the controls. And at first, everything is okay, so we forget about the issue. Fraudsters don’t forget. They are paying attention to whether you’re paying attention. Next thing you know, you’ve paid millions of dollars for a scam you knew about but neglected.
What can we do better?
- Don’t forget about a scam just because it is old. Unless you’re guarding against it, it will be back.
- Detect patterns earlier and act on them immediately. The technology exsists now that could allow us to detect spikes in billing during the billing cycle and immediately implement stronger controls. We don’t have to wait until the end of the year to find out that we paid 10 times as much this year as last year.
- Think beyond the current emergency. Wheelchair fraud may be under control in a few years, but we can use what we learn fighting wheelchair fraud to implement controls that will protect our entire system. See 10 Steps to Dramatically Decrease Healthcare Fraud.