Durable Medical Equipment (DME) is medical equipment that is used repeatedly. Often DME serves a medical purpose and is appropriate in a patient’s home or residential setting. Certain types of DME are particularly vulnerable to billing abuses. For example, an investigation of a large wheelchair supplier found that the company had submitted false claims to Medicare and Medicaid, including claims for power wheelchairs that beneficiaries did not want, did not need, or could not use. In 2004, it is estimated that Medicare and its beneficiaries paid $96 million for claims that did not meet Medicare’s coverage criteria for any type of wheelchair or scooter and that they overspent an additional $82 million for claims that could have been billed using a code for a less expensive mobility device.
The United States spends more than $2 trillion on health care every year. At least 3 percent – or more than $60 billion each year – is lost to fraud. Funds improperly paid and excessive reimbursements for certain items and services deplete needed resources from the health care system
Where do we see Durable Medical Equipment / Medicare fraud?
- Institutional facilities, such as nursing homes, residential facilities, hospitals, and hospices.
- In billing for physician services or visits to physicians (Medicare Part B).
- Billing for DME such as wheelchairs, body jackets, incontinence supplies, etc.
- In improper marketing through telephone, door-to-door sales and flyers (Medicare Part C (Medicare Advantage) and Part D (prescription drug benefit)).
DME / Medicare fraud is committed when a provider:
- Submits bills for services not rendered: Common are “gang visits”, when practitioners visit a nursing home and bill for services for all, or nearly all, residents. The physician may not have provided the service(s) to all residents but bills as if he or she had, or, the physician may provide service(s) whether every resident needs it or not.
- Upcodes a service: Submitting a bill for surgery when only a bandage was placed over a cut, for example.
- Unbundles services: Submitting separate billing for lab services that include three or four tests combined as one and which are supposed to be billed as one service. This separate billing results in Medicare paying providers more for each service than what would have been paid if they had been billed as a group.
- Solicits, offers, or receives a bribe or a kickback: Often recruiters or what are called “cappers” may stop beneficiaries on the street, or knock on their door and offer money or promotional gifts as incentives to entice them to take a “free” medical exam. Then the patient is presented with a list for durable medical equipment (DME), or prescribed DME that they do not need.
- Bills “non-covered” services as covered services: For example, billing routine toenail clipping (non-covered service) as foot surgery (covered service).
Find out more about: Medicare Fraud in South Florida
Our firm is only investigating claims in which a business entity, such as a company or medical practice, is submitting false claims to a governmental entity in excess of $500,000. We do not handle cases involving individuals receiving government benefits under false pretenses. (For example, we do not handle claims in which a person falsely claims disability in order to receive government benefits. ) For these claims, you should contact the appropriate governmental agency directly, such as a state medicare-fraud hot line, and report the fraud. Regarding tax fraud, we are only handling cases in which the underpayment of taxes exceeds $2 Million, and the income of the person committing tax fraud exceeds $200,000 per year.