To my fellow DME operators we need to help eradicate fraud from our industry.
Say it fast, the way our industry always does: fraud-waste-and-abuse. FWA. One acronym, pronounced like one word, policed like one crime.
It isn’t one thing. It’s three.
Fraud is billing for what never happened. A crime.
Waste is billing for what happened but helped no one. Legal, routine, invisible the resupply boxes that keep shipping to a patient who quit therapy in March.
Abuse is the gray zone in between. Technically billable. Clinically indefensible.
Here’s what I’ve come to believe: these aren’t three diseases. They’re three symptoms of one disease: a payment system that pays for volume on paper instead of results in the home.
And you can’t cure a disease by treating its symptoms. Fifty years of audits are the proof.
Credit where it’s due: CMS gets the front door exactly right. Screening new suppliers, site visits, background checks, surety bonds stopping bad actors before they can ever bill. Every crook turned away at the door is a thousand audits that never have to happen to the rest of us. Thank you for guarding it.
But the back end tells a different story. CMS’s own data puts DME improper payments at 21.4 percent more than three times the Medicare wide average. Yet when denials actually get challenged, most turn out to be wrong: one federal review found 75 percent overturned, and in the latest data it’s over 80 percent. And roughly nine in ten denials are never challenged at all just absorbed, written off, forgotten. That’s not fraud detection. It’s a paperwork lottery, and suppliers, patients, and CMS are all paying to run it.
The fix isn’t more audits. It’s payment design.
Fraud: pay for verified results. A crook can fake a signature. He can’t fake a year of nightly device data from a real patient getting real benefit.
Waste: when revenue requires a result, billing with no result behind it simply disappears.
Abuse: when doing the right thing pays better than billing the maximum, the gray zone reprices itself.
Nobody’s character has to change. The contract changes.
That’s why Eastern MedTech is moving to what we call Earned Care: we earn more when our patients do better. We earn less when they don’t.
To CMS: keep the strong front door. We’re not asking you to audit less. We’re offering a design under which you’d need to.
To my colleagues: the people were never the problem. The structure was and structures can be redesigned. Let’s be the industry that helps hold the pen.
