CMS and the Department of Justice have determined that fraud in the supply of durable medical equipment [DME] is a widespread and rapidly growing problem. According to a 2005 report by the Government Accountability Office, fraudulent payments accounted for more than $900 million in the US$8.8 billion spent on durable medical equipment in the United States in 2004. Medical insurance and Medicaid bear at least part of the cost of medically necessary equipment. In order to qualify for Medicare reimbursement, the patient must have a medically required certificate signed by the physician and must comply with any applicable medical insurance clinical guidelines to understand the medical necessity of certain devices, such as household oxygen or insulin pumps.
Many DME suppliers simply act as "intermediaries", purchase equipment from DME manufacturers, ship them to patients, and billing insurance, including Medicare and Medicaid. Therefore, supervision is difficult and patients are at risk of fraud. Common fraud schemes developed and implemented by DME fraudsters, as well as confirmed and prosecuted by the Ministry of Justice and official informants, including:
[a] delivering the DME to the patient prior to obtaining a doctor's order, a medical necessities certificate or a patient transfer benefit;
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[b] billing Medicare for repeated orders for DME, or be careful to "excessively" order DMEs that have never been ordered and exceed DME's guidelines and useful life;
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[c] DME "splitting" items purchased from the manufacturer and billing the United States multiple times for the components;
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[d] "upcoding" DME: to issue to the United States more expensive items than the actual items shipped;
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[e] DME medical insurance that has not been returned to the patient is included in medical insurance;
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[f] distort the patient's payment obligation to DME or waive the co-payment or deductible owed by the patient;
This fraudulent program is on the rise nationwide and even becomes an emerging market for organized crime and gangs. In order to combat the abuse of the system by criminal entrepreneurs, the Inspector General of the Ministry of Health and Human Services, in cooperation with the US Attorney General, created a task force called the HEAT Team [Medical Fraud Prevention and Enforcement Action Team].
However, the most devastating DME fraud continues to be a priority for larger, seemingly respected companies in our country's healthcare system. Affected by the structure of the company, these companies often affect a large number of geographical patient groups, but their false claims on medical insurance and Medicaid may be relatively small, and street actions of blatant crimes are more difficult to detect. In addition, it is very difficult to prove that these companies and managers who manage these companies have criminal intent to defraud medical insurance and Medicaid systems. Therefore, civil statutory instruments such as the federal "false declaration law" can better combat this large-scale enterprise DME false billing scheme. More importantly, the "false reporting method" includes a qui tam [or whistleblower] clause that encourages insiders to report fraud.
According to the federal government and some state false claims bills, whistleblowers can file lawsuits against fraudulent DME companies and can share up to 25% [and in some cases 30%] rewards. However, it takes courage to blow the whistle of corporate fraud, and the law rewards courage through certain protections. The "false declaration law" stipulates that the whistleblower's case must be filed in a sealed manner and requires the identity of the whistleblower to be protected during the government investigation.
In addition, federal law prevents retaliation by forcing a return to the wrong dismissal at the same level of qualification, as well as double payments, interest and attorneys' rewards. cost. In the past two decades, more than $22 billion in taxpayer funds have been recovered under the "false declaration law". Because of all the efforts and success of government and private advocates to regulate Medicare and Medicaid under the False Claims Act, the only way this fraud can be effectively implemented is to whistle the knowledgeable.
©2011 James F. Barger, Jr.
Orignal From: DME Health Insurance Fraud: Fighting Sustainable Medical Device Fraud and False Filing Acts
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