Durable Medical Equipment Fraud
Durable medical equipment (DME) fraud continues to be a significant source of fraud affecting insurers, government agencies, and patients who rely upon this equipment for their ongoing health needs. Durable medical equipment (also known as durable goods, medical supplies and home care products) is defined as items or appliances that:
- Can withstand repeated use
- Are primarily and customarily used to serve a medical purpose
- Are most useful to ill, injured or disabled people
- Are appropriate for home use, and/or
- Are necessary for one or more daily living activities.
To be covered under Medicare and Medicaid, a physician must order the equipment through a “Certificate of Medical Necessity” (CMN) which is sent to a supplier who fills the order and can then file a claim with the appropriate state or federal healthcare program.
Types of Durable Medical Equipment Fraud
Common types of fraud relating to DME often involve versions of the following scenarios:
- Billing for equipment or supplies that were never provided
- Billing for products that were no longer medically necessary or were not ordered by the treating physician
- Billing for or providing a more expensive product that the one the patient was actually provided
- Kickbacks from suppliers to physicians for referrals
- Submitting claims for nonexistent patients by using borrowed social security numbers
These schemes, when they result in fraudulent payments from government-funded healthcare programs like Medicare and Medicaid, can constitute violations that can be the basis of a qui tam whistleblower lawsuit under the Qui Tam provision of the False Claims Act.