Letter to Congress

Letter to Congress

Sara Beck

4/8/2013

I have received a few requests to see a sample
letter I have written to congress regarding Medicare’s audits.  Below is one of many letters I have written
to the congressman in my district. I figured it would help and encourage other
providers in contacting their representatives and/or speaking out against these
audits:
 Dear Congressman McNerney,
I am writing to you, on behalf of every medical
office and provider, in a desperate plea for assistance.  As you know, Medicare has released a
destructive wave of pre-payment and post-payment audits that has caused a
severe hardship for all medical providers and Medicare beneficiaries.  Speaking from everyday experience, I predict that the Medicare audits
unleashed in the past year and a half will cause all medical providers to
refuse services to Medicare patients; leaving our disabled and elderly
community without medical care.  This
prediction has already begun to take effect; as many medical providers have
presently begun denying services to Medicare patients in order to avoid the
unreasonable and excessive audit process. 
I
understand the immediate national need to reduce health care costs and we certainly
must find and prosecute actual fraud, and I also understand and sympathize with the
government’s current budget restrictions.  However, the audits implemented by CMS are not about fraud nor are they concerned with abuse and wasteful spending, they
are about excessive government paperwork demands that prohibit and restrict
medical care to Medicare beneficiaries and leave legitimate medical providers
with millions of dollars in debt scrambling to stay afloat. Just to give you a quick example of the harm
being caused by CMS and their contractors, I give you the following real-life example
(due to privacy laws, the patient will be referred to as “Mr. X”):
 
Mr. X is a bilateral
amputee who was very active; walked without any walking aid; and depended upon
his two prosthetic limbs to accomplish his daily activities.  He developed considerable problems with his left
residual limb due to heavy use of the prosthesis and significant residual limb
changes.  This caused his left prosthesis
(which was several years old) to rub on his limb so severely that he developed
several sores which caused him to be placed on pain management medication.  The prosthesis was extremely unsafe and was
causing Mr. X to fall and endure unbearable pain. He was also at risk of
infection and/or further amputation. Mr. X was then forced to use a walking
cane and was limited to only leaving his home for medical appointments.  At the request of Mr. X’s referring
physician, my office provided him with a new left prosthesis.  With this prosthesis, Mr. X no longer
required a walking cane or pain medication, and was no longer restricted to his
home.  However, Medicare denied this left
prosthesis due to “lack of sufficient physician clinical notes.”  Conversely, the referring physician
exhaustively expressed the medical necessity of the new prosthesis in FOUR separate
documents, including TWO sets of clinical notes.  But because Medicare was dissatisfied with
the physician’s notes based on an erroneous interpretation of their rules and
regulations, the entire claim was denied and my office was left with $8,000 of
debt we spent to fit and fabricate the prosthesis.  Now, Mr. X has developed significant problems
with his alternate (right) prosthesis and is at a high risk of infection and/or
hospitalization admittance without a new prosthesis on the right side.  But, because Medicare still refuses to pay
for the left prosthesis, we cannot provide any further services.  So, Mr. X is going without necessary medical
care and health is put considerably at risk because of Medicare’s unreasonable audits. Is this worth it? Is this patient's life worth it?
 
 
I
encourage Medicare wholeheartedly to eliminate fraud and wasteful spending.  However, the process must be fair and
reasonable for all parties involved.  And
the process, itself, must not be committing the exact dishonest actions in
which the audits were implemented to prevent from providers. The purpose and intent of the Medicare audit
system, as expressed to the general public, is to prevent fraud and abuse from
medical service providers; but the audits are not fulfilling their purpose and have greatly derived from their purported incentive. Fraud is defined by Medicare as “the
intentional representation that an individual knows to be false; such as,
billing for services or supplies that weren’t provided.”  In the above audit example, it is fully
documented that my office did, in fact, provide the exact prosthesis which was
billed.  Therefore, our services were not
fraudulent.  Next, Medicare defines abuse
as “behaviors or practices of providers…that are inconsistent with accepted
sound medical, business, or fiscal practices; such as, excessive charges for
services or supplies, claims for services not medically necessary.”  In the above stated case, the charges were
not excessive and were deemed medically necessary by the referring physician
and prosthetist because the patient was enduring significant pain and was at
risk of falling or potential life-threatening infection.  Again, the services are proven, and
acknowledged by Medicare, NOT to be wasteful or abusive.  In fact, our services saved Medicare hundreds
of thousands of dollars in hospitalization costs, physician fees and possible convalescent
admission that would have been incurred by the patient developing infection or
suffering a falling accident.  Additionally,
this patient is now suffering with agonizing pain and developing sores on his
alternate side that will progress into infection and/or further amputation, but
he will not receive the necessary care because of Medicare’s excessive,
prejudicial audits.
 
This
is just one example of 27 audits I have that expressly verifies Medicare’s
audit system is deeply flawed and is causing more harm to beneficiaries and their
providers.  The medical providers, particularly
small businesses, within your district will not survive if immediate legislative
action isn’t taken. 
 
I feel it is imperative that congress and our
legislature become aware of this growing problem. I know that legislative
assistance is the only action that will save our medical community and its
patients.  I would be happy to answer any
questions or concerns you may have regarding this issue.
 
Thank you for taking the time to review my analysis
and I look forward to your response.
 
Best regards,

Sara Beck
San
Joaquin Orthotics & Prosthetics