Fraud in the delivery of durable medical equipment (DME) has been identified by CMS and the Ministry of Justice as a pervasive and rapidly growing problem. According to a 2005 report by the Government Accountability Office, in 2004, monumental payments accounted for more than $ 900 million of the $ 8.8 billion spent by the United States on durable medical devices. Medicare and Medicaid cover at least part of the cost of medical equipment. To qualify for Medicare compensation, a patient must receive a certificate of medical need from a doctor and must comply with any applicable Medicare clinical guidelines for medical need for certain equipment (such as home oxygen or insulin pumps). ).
Many DME providers act simply as “average people” by purchasing equipment from DME manufacturers, sending them to patients and billing insurance, including Medicare and Medicaid. Thus, regulation is difficult, and patients are at risk of fraud. Common fraud schemes developed and perpetrated by DME fraudsters, and identified and held accountable by DOJ and qui tam whistleblowers, include:
(a) delivery of DME to patients before obtaining a doctor’s order, a certificate of medical necessity or the appointment of benefits by patients;
(b) Medicare billing for duplicating DME orders or careful DME “oversight” that has never been ordered and has not exceeded DME usage guidelines and longevity;
(c) “segregation” of DME items purchased from manufacturers and invoicing the United States several times for component parts;
d) “Recoding” DME: Billing in the United States for more expensive goods than actually shipped;
(e) inability to lend Medicare to DME, which is returned by the patient;
(f) misrepresenting patient payment obligations for DME or refusing co-payments or deductions due to patients;
Such fraudulent schemes are growing throughout the country and even become emerging markets for organized crime and gangs. In order to combat criminal entrepreneurs from abusing the system, the Inspector General of the Department of Health and Human Services has teamed up with the United States Attorney General to create task forces called HEAT (team for the prevention and prevention of health fraud).
However, the most devastating DME fraud in our nation’s healthcare system remains a priority for large, seemingly respected companies. Covered by the corporate structure, such companies often affect a large geographical population of patients, but their false claims against Medicare and Medicaid may be even harder to detect than smaller, frankly criminal operations at the street level. Moreover, it is extremely difficult to prove that such companies and managers who manage them have the criminal intention to deceive Medicare and Medicaid systems. Thus, civilian regulatory tools, such as the federal false claims law, are better equipped to deal with such large corporate DME false billing schemes. More importantly, the False Claims Act contains a qui tam (or whistleblower) clause that encourages insiders to report fraud.
According to federal and some state fake claims, whistleblowers can file a lawsuit against counterfeit DME companies under the seal and can participate in up to 25% (and in some cases 30%) awards. However, inflating the whistle on corporate fraud requires courage, and the law rewards this courage with some protection. The False Claims Act provides that the case of the informant must be filed under seal and in order to certify the informant, who must be protected during the investigation of the government.
In addition, federal laws protect against retaliation by authorizing the restoration of unlawfully fired employees at the same level of seniority and awarding double remuneration, interest, and lawyers; fees. Over the past two decades, in accordance with the Law on False Claims, more than $ 22 billion in taxpayer funds have been withdrawn. Since all efforts and successes from public and private lawyers controlling Medicare and Medicaid programs in accordance with the False Claims Act, the only way to effectively carry out such fraud is that people with knowledge can blow a whistle.
© 2011 James F. Barger, Jr.
