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Wednesday, October 8, 2008

Sleuths go door to door to sniff out Medicare fraud

MIAMI — Medicare investigators Suzanne Bradley and Cecilia Franco rap on an apartment door a little before 10 a.m. on a muggy Thursday.

They're seeking an 86-year-old man — allegedly a homebound diabetic whose home health care agency is billing Medicare for daily visits by a nurse to help him inject insulin. He wasn't home when they stopped by twice the day before, but this time they hear someone inside.

"We're from Medicare. We'd like to speak with you," says Franco, the Miami Field Office director for the Centers for Medicare and Medicaid Services (CMS).

Visits such as this one late last month are part of an effort to battle Medicare fraud in one of the nation's hot spots for such scams: Miami-Dade County.

Today they are focusing on home health agencies that send nurses to give homebound diabetics insulin injections. Some patients are neither homebound nor unable to give themselves the injections, Bradley and Franco say. Some don't even have diabetes.

Unless the agencies are caught, though, Medicare still pays them. Home care costs in Miami range from $300 for a 60-day treatment period to more than $27,000, CMS data show.

The focus on home care in Miami comes amid scrutiny of Medicare's anti-fraud efforts, including a series of recent congressional reports describing questionable payments to medical providers nationwide.

Today, acting CMS Administrator Kerry Weems plans to outline new measures to combat inappropriate payments. Among them: actions targeting Miami-Dade home health agencies.

By the time Bradley and Franco leave the man's apartment, he has admitted he goes out for walks and takes the bus regularly, so he isn't technically homebound. He tells them Medicare pays for an aide who comes three times a week to clean his home.

Yet dust covers the knick-knacks in the apartment and spills soil the kitchen floor. He says the nurse comes each day because he's afraid of pinching himself when injecting insulin.

It isn't clear, the investigators say, if he really does need a nurse to help with his insulin shots or if he needs injections at all. But one thing is apparent: "He doesn't need the aide," Franco says.

If nervousness about self-injections was a qualifier for home health care, "we'd be paying for every diabetic in the country," Bradley says. [Mark Godsey]

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