Compliance Note

DME Fraud In The News: Fraudulent Payments For Urinary Catheter

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Seven durable medical equipment companies may have cost the Medicare system as much as $2 billion in fraudulent payments for urinary catheters for nearly 406,000 patients. Seven companies allegedly operating out of Connecticut, Florida, Kentucky, New York, and Texas were behind a surge of bills submitted to Medicare across the last two years. The fraudulent billing has been associated with a security breach of patient information and illegal marketing schemes aimed at obtaining Medicare patients’ personal information.

 

According to CMS, scammers target Medicare enrollees through phone calls, internet ads, and text messages with offers of free services, medical equipment, or gift cards upon confirming their personal information and eligibility for specific Medicare services. Often, the enticement for the individual is that they are "qualified" for items "at no cost" or "free." Once the scammers obtain the enrollee's personal information, monthly billing to Medicare will begin for medically unnecessary urinary catheters that may or may not actually be sent to the enrollee.

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Fraudulent billing affects the ACO's ability to earn savings, can create losses, and directly affects physician payments from the ACO.

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Components Of Home Health Fraud

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Home health fraud usually involves bills for services that are not recommended by a medical practitioner, or for services that have not been provided. 

 

• High percentage of episodes in which the beneficiary had no recent visits with the supervising physician

 

• High percentage of episodes that did not progress from a nursing home or hospital stay

 

• High percentage of episodes with a primary diagnosis of hypertension or diabetes

 

• High percentage of beneficiaries with a high percentage of beneficiaries who received home health care from three or more HHAs

 

• High percentage of beneficiaries with home health readmissions over a short period of time

 

Patients should be cautious of unsolicited requests for Medicare numbers. No one other than the provider's office should ever request Medicare information, and there is no other circumstance when it is appropriate or safe to provide it.

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References 

1“OIG Report Identifies Common Characteristics In OIG Home Health Fraud Cases.” Van Halem Group, 5 Dec. 2015, www.vanhalemgroup.com/blog/post/oig-report-identifies-common-characteristics-in-oig-home-health-fraud-cases/.

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Understanding Medicare Coverage For Home Healthcare

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As part of Genuine Health Group’s commitment to compliance and patient well-being, it’s crucial to understand the nuances of Medicare coverage for home healthcare. Medicare Parts A and B encompass intermittent or short-term home health services, provided by Medicare-approved agencies in collaboration with physicians to ensure comprehensive care for patients. 

 

Here's what you need to know about eligibility and preventing potential fraud in home healthcare services.

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Eligibility For Medicare Coverage

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For Medicare coverage of home healthcare services, certain criteria must be met:

 

1. Medical Necessity: It must be medically necessary for the patient to receive skilled care services at home. These services may include part-time nurse and nurse aide visits, rehabilitation services like physical therapy, occupational therapy, speech-language pathology, and medical social services.
    

2. Expectation of Improvement or Maintenance: The patient’s condition should either be expected to improve within a reasonable timeframe or require skilled therapy to maintain or prevent further deterioration.
    

3. Homebound Status: The patient must be considered "homebound," meaning they are unable to leave home without assistance, requiring considerable effort, or posing a danger to themselves due to their health condition. However, limited exceptions allow for medical appointments and short outings.

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Examples Of Home Healthcare Fraud

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Unfortunately, instances of home healthcare fraud can occur, impacting both patients and the integrity of the healthcare system. Here are some examples to be vigilant about:

 

• • Billing for Non-Qualified Services: Medicare is billed for home health services that do not meet the criteria for medical necessity or homebound status.
     

  • False Enrollment: Patients are enrolled in home health services by unfamiliar doctors or agencies without their knowledge or consent.
     

  • Coercion for Medicare Information: Patients are offered incentives such as groceries or rides in exchange for Medicare information or switching to a different agency.
     

  • Fraudulent Charges: Patients are billed copayments for services that Medicare should cover, or they're asked to sign forms for services they did not receive.
     

  • Misrepresentation of Services: Services provided, such as housekeeping or medication assistance, are billed as skilled nursing or therapy services.
     

  • Offer of Incentives: Patients are offered cash or gifts to participate in fraudulent schemes.

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Preventing Home Healthcare Fraud

To combat home healthcare fraud and protect patients, it's essential to take proactive measures:

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• Educate Patients: Encourage patients to review their Medicare Summary Notices or Explanation of Benefits to verify services billed and received.
   

• Ensure Proper Enrollment: Patients should only enroll in home health services through their treating physician or trusted healthcare providers to guarantee medical necessity.
   

• Reject Incentives: Advise patients not to accept gifts or incentives in exchange for home health services.
   

• Be Cautious of Solicitations: Warn patients against signing up for services from unfamiliar individuals who approach them at their doorstep.
   

• Report Suspicious Activity: Patients should report any discrepancies or fraudulent charges on their Medicare statements promptly.​

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