Once upon a fraudulently claimed mattress


I just read an old indictment announcement from the FBI that recalled themes of durable medical equipment fraud, sales quotas, and the temptations for people to throw themselves off legal and ethical cliffs to make money.

Mary Monica Wilson-Lefler worked as a salesperson with two durable medical equipment companies in Pennsylvania. She sold powered, pressure-reducing mattresses--or PPRAMs--designed to reduce the likelihood of skin ulcers on bedridden patients. She visited long-term care facilities to find beneficiaries who would benefit from these mattresses, and she handled all paperwork necessary for the DME companies to claim insurance payment for the PPRAMs.  

To be eligible for Medicare benefits, PPRAMs must be ordered by a doctor in writing. Wilson-Lefler faxed attending physicians the order requests for PPRAMs. But the government said her faxes falsely reported the beneficiaries had serious bed sores. Some of the reports allegedly contained forged signatures of facility staff and attending doctors.  

"In reality," the FBI announcement stated, "none of the patients had serious skin ulcers or any other qualifying conditions that would meet the Medicare coverage requirements." The scam involved approximately 83 patients in four facilities, with billings totaling about $200,000. Wilson-Lefler eventually pleaded guilty to healthcare fraud.

Looks like Mary Monica was a go-getter on the job. I wonder if her pay was based on the number of mattress claims reimbursed to her partner companies. Did she see the line between assertively selling an item that could prevent pain for beneficiaries and making false claims?

It can be challenging to stay on the right side of that line, especially for sales professionals. A "harmless" lie here and there, an exaggeration or embellishment of facts to close the deal. These are easy traps, and many fall into them. They can lead to more brazen lies and schemes. That's one reason durable medical equipment fraud has poached government insurance programs for years. Approximately $6.4 billion in payments were made inappropriately for DME and related equipment authorizations in fiscal 2012.

I've worked with many salespeople who were ethical, driven and quick to curse the rules of doing government business. They experienced those rules as a bit in the horse's mouth, as inhibitors and constraints. "Why play by the rules when competitors get ahead by cheating?" they asked.

I'm sure it isn't easy to make a good living fair and square as an independent DME vendor or salesperson; but I've told people they'd have a far better day at work if federal agents weren't raiding their offices at 9:00 a.m. as a result of rule-breaking behavior.

As counterintuitive as it seems, compliance is about freedom. It's the freedom that comes from taking care of what must be done so you can soar into the possibilities of what can be done. And the truth--as most of us know--has a way of coming out. It's an energetic force that resists long-term suppression.

Those who commit healthcare fraud bet against this for the sake of fast money; they assume they won't get caught. Part of our job as fraud fighters is to make that bet clearly and predictably unsafe. - Jane (@HealthPayer)   

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