Forgive me for starting with the obvious: healthcare in the United States is a mess. Though each segment can be held up as an example of that statement, the DME (or HME) industry and its current situation is a great illustration of healthcare gone wrong.
I'll give a brief primer for those unfamiliar with DME.
The Introduction
Most DMEs bill Medicare for products needed by and delivered to the program's beneficiaries. The DME doesn't name the prices for the products, Medicare does via its fee schedule. That's an important statement that Joe Average citizen often doesn't know. If a DME is willing to accept the Medicare reimbursement rate, then the DME can bill the program for reimbursement. Yes that's an oversimplification, because DMEs must meet specific criteria to be accepted providers, but the important thing here is that DMEs have no control over what Medicare will or will not pay.
The fee schedule has seen many changes over the years. In the beginning, DMEs did name their own prices for products, and as a result Medicare over-paid. When the Medicare program finally caught on to over-paying, it introduced the fee schedule. Reimbursements have been cut many times since its introduction as CMS has caught on to what things really cost DMEs, which in turn has cut into profits.
The 2010 budget for Medicare was proposed at $453 billion which is a 6.5 percent increase from 2009. Medicaid was to be funded at $290 billion in 2010, up 12 percent from 2009.
Some of the claims that are submitted to Medicare are, unfortunately, fraudulent. I'm not talking about errors made by billers, which CMS seems to lump in with fraud statistics. I'm talking about DMEs who submit claims for products not actually provided to beneficiaries and other "creative" billing strategies that benefit no one but the provider doing the billing. And though DME costs for Medicare are a tiny fraction of the agency's budget, the agency claims that DME fraud is a huge issue (to the tune of $700 million in improper payments).
The Solution That Isn't a Solution
Medicare has made a big deal, in the press and with Congress, about DME fraud. To combat fraud, the agency has, with the assistance of lawmakers via legislation, mandated accreditation, surety bonds, and implemented a competitive bidding program.
So what's the solution that isn't a solution? Competitive bidding.
The industry has been fighting a competitive bid for many years. In the late 90s it fought the bid demonstrations in Florida and Texas, and in early 2000 it fought a bid program until the industry lost that fight when the bid was mandated in MMA 2003.
Here's the unfortunate truth: There was and still is fraud in DME. It might be more difficult to commit fraud these days, but it's still very much around. I don't know about you, but as a taxpayer, I resent being robbed. We all should. Will competitive bidding eliminate a lot of fraudulent providers? Sure it will. But it will also eliminate a lot of ethical ones, and that's cause for concern.
Enter the Heroes of the Story
The unsung heroes of our story are the organizations that have tried very hard for many years to preach ethics and unity to DMEs across the nation, delivering a consistent message, providing information, education, and leading grassroots efforts to make DME a better, more honest industry.
I'm talking about organizations that have been around and working hard for the long haul; I'm talking about associations like MAMES, MESA, NAMPS, NCAMES, NEMED, VADMEC, and a (very) few other long-established entities.
These groups have worked very hard to engage DME providers in their respective areas. And if they haven't been as successful as they would like, the fault is in the DMEs who haven't actively supported their efforts.
Of late there have been new organizations springing up, undermining the existing organizations and splintering an industry that's weak and vulnerable largely in part because of its own apathy (and laziness). Where were these people before the passage of MMA 2003? It's all well and good to be an activist now, but it's a general truism that it's easier to prevent a thing than to undo it. Yet here they are now, filing lawsuits, hiring lobbyists, and trying to make it appear as though their intervention is going to save the industry.
It's an unfortunate turn of events.
No lawsuit filed against competitive bidding has ever been successful. A lot of money has been spent on fruitless litigation; it hasn't proved to be a sound investment.
Then there are the various pieces of legislation introduced to delay the bid process. This worked a few years ago (you all remember the doc fix, right?), and might again if a Senator can be found to introduce a companion bill (no luck yet after months of searching). Nothing new or original here, and a delay doesn't make competitive bidding go away.
I've observed an unfortunate trend with these new organizations, and it's that they seem to try to get maximum exposure at the expense of the existing associations with whom they're competing (and make no mistake: they're competing for dues dollars). They allege that they do and accomplish what their competitors do not, though their "leaders" aren't very familiar with the established organizations, and so aren't really in a position to know if what they're saying is truth (I sometimes suspect that that isn't an important detail).
And because we live in a world where political correctness is extreme, and because no one is willing to court controversy, the long-established organizations continue to quietly do what they do so well without crowing about every step they take and without denigrating the new arrivals.
If the long-established organizations had had the active support of the johnny-come-latelys before MMA 2003, things would probably be different for the DME industry today. It's obvious that unity is needed. This is virtually impossible to achieve, however, when the national organizations are embracing anyone who comes along on the off chance of a miracle, thereby making themselves look good because they "supported" the newcomers. What the national organizations appear to be ignoring is that even if this isn't their motivation, perception becomes reality, and the already-low industry morale drops even more.
It's time for the established organizations to rethink their strategies, alliances, and approaches to the problem that is competitive bidding, because the industry can't afford to be without them; they do the lion's share of the work. They don't spend their time trying to hog glory; they spend their time trying to get the job done. This is why they're the heroes of this story.
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