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New federal probe targets physicians
If you routinely approve home health services or durable medical equipment (DME) and supplies for your Medicare patients without following federal guidelines for medical necessity certification, you could be facing charges of Medicare fraud.
Following an investigation of home health agencies and durable medical equipment suppliers, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services has issued a Special Fraud Alert warning physicians that they share responsibility and potential liability for appropriate provision of home care, DME, and supplies.
While the incidence of physicians intentionally submitting false certifications of medical necessity is infrequent, laxity in reviewing and completing the certifications contributes to fraud and abuse by suppliers and home health providers, the report says.
"The potential liability discussed in the Fraud Alert has always been there. Publication of this Fraud Alert may signal the start of enforcement activities. It’s a public warning to physicians that they are going to be held accountable for the items they prescribe," says Elizabeth Carder, JD, of Reed Smith Shaw &McClay, LLP, a Washington, DC, law firm.
She suggests that physicians be prepared in case their patients’ files are audited by making sure each patient’s chart contains information to support the need for the equipment or services prescribed. For instance, if a physician prescribes a wheelchair for the patient, the chart should note that the patient is not ambulatory.
According to the OIG, physicians may violate the law when:
• they sign a certification as a "courtesy" to a patient, service provider, or equipment supplier when they have not first made a determination of medical necessity;
• they knowingly or recklessly sign a false or misleading certification that causes a false claim to be submitted;
• they receive any financial benefit for signing the certification, including free or reduced rent, patient referrals, supplier, equipment, or free labor.
Physicians may be liable for making false or misleading certifications even if they don’t receive any benefit from providers or suppliers, the OIG asserts.
While physicians are not personally liable for erroneous claims "due to mistakes, inadvertence, or simple negligence," they will face criminal, civil and administrative penalties for knowingly signing a false or misleading certification, the report says.
"We are issuing this Fraud Alert because physicians may not appreciate the legal and programmatic significance of certifications they make in connection with the ordering of certain items and services for their Medicare patients," the report says.