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Medicare Durable Medical Equipment (DME) Fraud, Waste and Abuse

Author: Beth Perry    Posted: May 11, 2015

Medicare works diligently on its programs and billings to reduce the millions of dollars a year that are spent on fraudulent charges. Durable Medical Equipment is often at the center of these scams. Over the years bogus operations have been shut down, oversight has been put into place, and new rules enacted. One of the rules relates to the need for practitioner visits and written orders prior to delivery of certain equipment.

Medicare requires a doctor visit in order to certify need and medical necessity. Medical necessity is the physical or medical requirement for equipment or a procedure. Take for example a hospital bed. You might be more comfortable with a bed that raises your head or feet. This does not make a hospital bed medically necessary. However, if you have a respiratory condition (COPD) that is managed by raising your head while in bed, this could constitute medical necessity.

Medicare requires a practitioner visit within 6 months of the order and doctor orders to cover the following items:

  • (TENS) unit
  • Rollabout Chair
  • Oxygen and respiratory equipment
  • Hospital beds and accessories
  • Traction-cervical
  • Any item of durable medical equipment that appears on the DMEPOS with a price ceiling at or greater than $1000
  • Any item CMS places on the list to reduce Fraud, Waste and Abuse

The takeaway here is we all have a responsibility to reduce fraud waste and abuse by making sure the proper diagnosis and documentation is in place before DME is ordered. In the case of expensive equipment or procedures, it is always best to ask the provider and /or insurance company if authorization is needed before placing an order. That way you know you have done your part to prevent fraud and will not end up with a surprise bill later on.

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