Dme Billing And Insurance Claims: Navigating The Fine Line Between Cost-Saving Measures And Fraud

Durable Medical Equipment (DME) fraud is a significant issue within the healthcare system, with fraudulent billing accounting for 10% of Medicare billings. DME fraud involves companies charging patients for equipment that is not medically necessary or never delivered. This includes wheelchairs, prosthetic devices, oxygen tanks, orthotics, and other medical supplies. Fraudulent schemes also involve paying kickbacks or bribes to healthcare providers in exchange for referrals or prescriptions. Insurers often bear the cost of DME fraud, but law enforcement rarely prosecutes those involved, leaving private insurers vulnerable. To combat DME fraud, whistleblowers play a crucial role in exposing these schemes and can receive rewards for their efforts. By reporting suspected fraud and seeking legal assistance, individuals can help protect the healthcare system and ensure the safe and necessary use of DME.

Billing for products not delivered

Durable medical equipment (DME) fraud is a costly issue for insurers, and it often goes unpunished. DME fraud includes fraudulent billing for all types of durable medical equipment, such as wheelchairs, prosthetic devices, portable oxygen tanks, and orthotics. One common form of DME fraud is billing for products that were never delivered to the patient.

In the context of DME fraud, billing for products not delivered can occur when DME companies obtain the names and addresses of Medicare recipients and bill Medicare for equipment that is never sent. This scheme may also involve providing equipment to those not eligible for Medicare or Medicaid while still billing the government.

To protect themselves from such fraud, insurers can take affirmative steps to investigate and detect fraudulent schemes. They can also hire lawyers to take legal action to recover losses due to fraud and prevent future fraud. Additionally, individuals can play a crucial role in identifying and reporting DME fraud. If you suspect DME fraud, you can contact your supplier, call Medicare, or file a complaint through the Medicare website.

Beyond the context of DME fraud, there are other scenarios where individuals may encounter billing for products not delivered. For example, in online shopping, scammers may set up fake websites or profiles on legitimate selling platforms to deceive individuals into paying for products that are never delivered. In these cases, it is important to verify the legitimacy of the website or seller before making a purchase.

In general, if you suspect billing fraud, it is important to monitor your credit card and bank account activity regularly. Notify your bank immediately if you notice any unauthorized charges. You may also need to report the fraud to your credit card company, file a police report, and submit a fraud claim with the retailer. By taking prompt action, you can help protect yourself from fraudulent charges and contribute to exposing and preventing scams.

Billing for higher-cost products than those delivered

In this scheme, the DME company will deliver a product to the patient but will bill the insurance company for a more expensive item. For example, a patient may receive a basic wheelchair but the DME company will bill the insurance company for a motorized wheelchair. This is often referred to as "upcoding".

This type of fraud is challenging to detect without access to the financial records of the DME company. However, there are some red flags that insurers can look out for. For instance, they can examine the volume of DME being billed for a patient with relatively minor injuries. They can also investigate whether DME suppliers are billing for multiple items of the exact same type of DME for each patient.

Additionally, patients themselves can help identify this type of fraud by carefully reviewing their Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) for any discrepancies. If patients notice any charges for equipment they did not receive or did not need, they should report it as potential fraud.

Billing for new equipment when the actual equipment was used

DME companies have been known to bill insurance carriers for new equipment when the equipment provided was used. This is a violation of the law, as DME suppliers are required to disclose whether the equipment is new or used. If they do not, and the insurance company ends up purchasing the equipment for the "new" price, the customer has been scammed.

To avoid this scam, it is important to always confirm that the charges submitted to your insurance carrier are correct. Be wary of companies that advertise that they can get your insurance company to pay for the equipment, as ultimately, the cost is passed on to the customer if fraud is involved.

If you suspect that a DME company is cheating, you can report them. To file a complaint about DME, you can contact your supplier or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Your supplier must then let you know that they have received your complaint and are investigating it within 5 calendar days, and they must send you the result of your complaint and their response in writing within 14 calendar days.

Billing for a DME product that was never needed or requested

Durable Medical Equipment (DME) fraud is a costly and prevalent issue for insurers, and it can take many forms. One such form is billing for a DME product that was never needed or requested. This can occur when a DME company provides unnecessary equipment to a patient and then bills Medicare or Medicaid. To do this, the company must certify that the equipment was medically necessary, and if they lie or provide false information, it is considered fraud.

For example, in the case of USA v. Brandy, the defendant, a DME supplier, submitted bills to Medicaid and collected over $10 million for DME that was never prescribed or received by patients. Some of the Medicaid bills were for patients who had already passed away.

To prevent this type of fraud, insurers can take several steps, including:

• Regularly reviewing their financial records to look for suspicious activity, such as checks cashed at a check-cashing facility or deposited into an account not belonging to the DME supplier.
• Conducting investigations to answer questions such as whether a DME supplier is submitting bills for a large volume of DME for a patient with minor injuries, or whether patients with minor injuries are receiving a large volume of DME.
• Educating staff on proper billing procedures and industry guidelines to ensure clean claims are submitted and timely payments are received.
• Outsourcing billing services to specialists who can process claims, check claim status, and stay current on payer guidelines.

By taking these steps, insurers can help to protect themselves from the financial and legal consequences of DME fraud.

Billing for DME when no DME was provided

Durable Medical Equipment (DME) fraud is a costly issue for insurers, and it can take many forms. One of the most common schemes is billing for DME when none was provided. This type of fraud can be difficult to identify, as it often relies on fraudulent billing practices that are hard to detect without access to financial records.

Billing for DME when none was provided is a serious issue that can result in significant financial losses for insurers. In this scheme, DME suppliers fraudulently submit bills for DME that was never prescribed or provided to patients. This can involve billing for specific DME when a cheaper alternative was provided, or billing for DME that was never ordered by the treating physician.

To prevent this type of fraud, insurers can take several steps. Firstly, they can educate themselves about the different types of fraudulent schemes, including the billing for DME when none was supplied. Insurers can also implement measures to detect fraudulent billing practices, such as examining their financial records for suspicious activity. For example, if checks are being cashed at a check-cashing facility or deposited into an account not belonging to the DME supplier, this may indicate fraud.

Additionally, insurers can work with law enforcement and hire lawyers to take legal action to recover losses and prevent future fraud. They can also encourage whistleblowers to come forward by offering rewards and ensuring their protection. By staying vigilant and proactive, insurers can better protect themselves and their customers from the harmful effects of DME fraud.

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