Medicare and/or Medicaid pays for certain durable medical equipment (DME) when it’s been ordered by your physician through the issuance of a Certificate of Medical Necessity, or CMN. What is durable medical equipment? It’s typically medical equipment that can be used repeatedly and is often used in the patient’s home or other place of residence, such as a nursing home.
Examples include wheel chairs, body jackets and incontinence supplies.
Once a Medicare or Medicaid beneficiary furnishes their CMN, the DME provider furnishes the equipment and then bills the government health care program for the equipment.
Some types of equipment seem to lend themselves to wholesale Medicare fraud. Wheelchairs are a prime example. For instance, in 2004, estimates are that Medicare and its beneficiaries paid $96 million for claims that did not meet Medicare’s coverage guidelines for any type of wheelchair or scooter.
What’s more, both groups may have overspent an additional $82 million for claims that could have been filled with a less expensive device.
Government estimates say that $60 billion, or less than 3% of the 1998 total health care total spend, was lost to fraud.
Where are many of the abuses seen in the Medicare fraud cases brought before the courts?
- All types of institutional facilities, including nursing homes, residential facilities, hospitals, and hospices.
- Billing for all kinds of DME: wheelchairs, body jackets, incontinence supplies.
- Improper marketing practices through telephone, door-to-door sales and flyers.
- Bills submitted for services not rendered. One example would be "gang visits". This is when practitioners come to a nursing home and bill for services for all, or nearly all, residents, whether they were provided, or needed or not.
- Service upcoding: Billing for a minor surgery when only a bandage was placed over a cut, as an example.
- Services Unbundling: Submitting separate bills for lab services that include multiple tests combined as one and which are supposed to be billed as one service. This means Medicare gets stuck with a higher bill than would have been the case.
- Recruiting Medicare eligible people to take unneeded exams. The patients are then told they need DME, Medicare gets billed and the patient may, or may not, get the equipment.
To avoid unknowingly becoming participants in Durable equipment Medicare fraud, patients should be wary of providers soliciting their business or offering any kind of payment or kickback for them to take an exam. Patients should be especially vigilant anytime a sales representative pushes equipment or tests and procedures on them.
Report Durable Medical Equipment Fraud/Medicare fraud here.
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