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Physicians take heed: the Office of Inspector General last Thursday released a model compliance plan for durable medical equipment companies that reiterated warnings to physicians it issued in a DME fraud alert two weeks ago.
The model plan covers some of the same ground, hammering home the OIG's demand that suppliers — and the physicians they deal with — must be accountable for appropriately certifying the medical necessity of all prescribed equipment.
Indeed the first two risk areas listed in the guidance are billing for items or services not provided, and billing for medically unnecessary services, which the OIG defines as "seeking reimbursement for a service that is not warranted by the patient's current and documented medical condition."
Certifications of medical necessity (CMNs) are required for fourteen items or services: home oxygen therapy; hospital beds; support surfaces; manual and motorized wheelchairs; continuous positive airway pressure devices; lymphedema pumps; osteogenesis stimulators; transcutaneous electrical nerve stimulators; seat lift mechanisms; power operated vehicles; infusion pumps; and parental nutrition and enteral nutrition.
While DME suppliers may fill out parts A and C of the certification, section B may be completed only by the treating physician, a non-physician clinician involved in the care of the patient or a physician employee who "is knowledgeable about the patient's treatment." If a physician employee completes the form, the treating physician or another authorized person must review the form to ensure its accuracy. Section D, the attestation statement, may be signed only by the treating physician or another person authorized to order equipment for the patient. Suppliers who complete section B themselves are subject to minimum civil monetary penalties of $1,000 per case, in addition to other civil or criminal liability.
The guidance warns physicians not to sign CMNs unless sections A through C are completed and correct. And signature and date stamps aren't acceptable.
"Physicians need to take some time before they fill these forms out," says Sue Raines, executive director of the Athens-based Georgia Association of Medical Equipment Suppliers. "[Errors] aren’t necessarily being made purposely, but they need to make sure that what they’re filling out is correct, because they are liable."
With regard to physician orders, the guidance stipulates that DME suppliers must write into their policies a statement that they won't bill for an item or service unless the treating physician or another authorized person orders it in writing. If a supplier receives a verbal order, it must document the verbal order and have the treating physician confirm it in writing prior to billing Medicare.
OIG also recommends that DME suppliers draft policies on what can and can’t be included in a cover letter to the treating physician that accompanies a CMN. Specifically, the OIG doesn’t want to see any diagnostic information on a cover letter. Such letters should only address issues related to policy changes from HCFA or a DME regional carrier, brief descriptions of the items being provided and changes in the patient's treatment regimen.
DME suppliers also aren't supposed to distribute completed "sample" CMNs to physicians. The guidance recommends that suppliers retain a copy of any cover letter it sends; and physicians might take the same advice.
Like other DME representatives, Raines supports federal efforts to rein in the fraud and abuse that analysts say has been rampant in the industry. She notes, however, that it’s becoming more difficult for fraudulent suppliers to prosper, thanks to new licensure laws in some states and the government’s new practice of verifying that DME suppliers have a physical location. "Things are tightening up, the way they should have a long time ago," Raines says. "Fraud and abuse have been a black eye on those people who are doing the right thing."