“Reasonable and Necessary”

The Houston Chronicle had a recent editorial about the two-part investigative series authored by Terri Langford about “unscrupulous operators who make millions of Medicare dollars exploiting the most vulnerable of our local residents through private ambulances and for-profit psychiatric clinics – with both scams feeding off each other.”  Below is part of the editorial:

Medicare, and American taxpayers, are footing the bill, which is enormous: Hundreds of private Emergency Medical Services vehicles carry patients every day – at considerable cost, and whether they need ambulance transportation or not – to so-called therapy programs in the Houston area. Langford, who spent more than a year researching her story, documented numerous instances of physically sound individuals repeatedly carried by ambulance to and from therapy.

What is almost as alarming as the rampant fraud is the fact that Medicare itself has made it easier for these scam artists to make a killing: Federal law enforcement agencies have, over the years, uncovered ample evidence of “kickbacks, fraud and the hunt for patients with Medicare benefits,” reported Langford. Harris County officials have complained to Medicare for two years of widespread fraud by private EMS companies, but said they received no response. And Medicare’s Texas billing contractor recently warned companies that, since 2007, it has targeted non-emergency transports in Texas as its number one problem.

One of the major hurdles to prosecution lies with the “physician certification statement,” like a prescription, explaining why a patient needs EMS transport, which the provider is required by Medicare to obtain before transporting a patient. Medicare stipulates that tax dollars can only be used when a ride is “medically necessary and reasonable,” and not when “some other means of transportation … could be used without endangering the individual’s health.”

But that is a vague stipulation, one that ties prosecutors’ hands. Another invitation to abuse is that the provider is never required to submit that statement to Medicare when processing a claim. Medicare should promptly clarify “necessary and reasonable,” and demand evidence of need. It should also beef up its investigative process and stop ceding control of its transactions to contractors. It’s a more than $700 billion agency. It can afford to invest a little to recoup some of the millions it’s currently losing in Houston.

While Medicare is in no way responsible for their illegalities, it has known for years that corrupt companies were making hay in Houston and did little to rein them in. It’s past time to get serious and put them out of business.