OIG fraud alert for home care and DME raises concerns


HHBR Washington Correspondent

WASHINGTON – Department of Health and Human Services (Washington) Inspector General June Gibbs Brown issued a Special Fraud Alert last week urging physicians to be certain only to authorize home health services and durable medical equipment (DME) and supplies for Medicare beneficiaries that are medically necessary. Brown expressed concern that some physicians are knowingly or unknowingly ordering home health services and DME inappropriately.

The Office of Inspector General (OIG) characterized the Fraud Alert as part of its overall efforts to root out fraud and abuse in the Medicare program. Brown called the Alert part of the OIG’s effort to "educate and remind physicians of the legal and programmatic significance of certifications" they make when ordering home health services and DME for Medicare beneficiaries. Some industry observers, however, see it as part of a larger pattern to further rein in utilization of home healthcare and DME. "My question is whether or not this is part of an effort to chill physician involvement in home health," remarked one veteran industry observer. "It is impossible to look at everything else that has transpired in home health over the last 18 months and not see a trend."

Under the Medicare program, physicians who prescribe home healthcare or DME (such as hospital beds, wheelchairs, and oxygen) must certify that these services or items are medically necessary and that the beneficiary meets the requirements to qualify for the benefit.

But the OIG’s critics noted that even Brown admitted physician fraud in this area is "infrequent" and said the evidence she cited was largely anecdotal.

According to the OIG, recent audits have revealed that physicians sometimes order home health services without properly assessing patient needs and that others have authorized unnecessary DME. To buttress these claims, the OIG cited several examples, including:

A physician knowingly signs a number of forms provided by a home health agency that falsely represent that skilled nursing services are medically necessary;

A physician certifies that a patient is confined to the home even though the patient tells the physician that her only restrictions are due to arthritis in her hands;

At the prompting of a DME supplier, a physician signs a stack of blank certificates of medical necessity (CMN) for transcutaneous electrical nerve stimulators units which are later completed with false information;

A physician signs CMNs for respiratory medical equipment falsely representing that the equipment was medically necessary;

A physician signs CMNs for wheelchairs and hospital beds without seeing the patients, then falsifies his medical charts to indicate that he treated them, and;

A physician accepts anywhere from $50 to $400 from a DME supplier for each prescription he signs for oxygen concentrators and nebulizers.

"A physician is not personally liable for erroneous claims due to mistakes, inadvertence, or simple negligence," said IG Brown. "However, knowingly signing a false or misleading certification or signing with reckless disregard for the truth can lead to serious criminal, civil, and administrative penalties." The criminal penalties could include criminal prosecution and fines as high as $10,000 per false claim, said the OIG. The administrative sanctions could include exclusion from participation in federal healthcare programs, withholding or recovery of payments, and loss of license or disciplinary actions by state regulatory agencies.