DME Medicare fraud: fight against durable medical equipment fraud by false claim law

Fraud in the supply of durable medical equipment (DME) is recognized as a problem spreading rapidly, widely spread by CMS and Ministry of Justice. According to the 2005 government report by the Government Accounting Office, the fraudulent payment amounted to more than $ 900 million out of the $ 8.8 billion US spending on endurance medical equipment in 2004. Medicare and Medicaid cover at least some of the cost of medically necessary equipment. In order to be eligible for Medicare refund, you must have a medical need certificate signed by your doctor. We must also meet Medicare clinical guidelines on the medical needs of specific equipment (such as home oxygen or insulin pumps).

Many DME suppliers simply purchase equipment from DME manufacturers, ship them to patients, and act as "mediators" for claims insurance, including Medicare and Medicaid. Therefore, regulation is difficult, and patients are at risk of fraud. Common fraud practices that were developed by DME fraudsters and identified and prosecuted by DOJ and qui tam internal correspondents include:

(A) shipping DME to the patient before obtaining a doctor's order, medical need certificate, or patient assignment patient.
(B) Medicare requesting DME to carefully "overheat" the DME's usage guideline and lifetime without duplicate ordering of DME or ordering.
(C) "unbundled" items of DME purchased from the manufacturer and charged to the United States multiple times for components;
(D) "Upcoding" DME: Request the United States for expensive items that are more expensive than what was actually shipped.
(E) It is not credited to DME's Medicare that the patient returns.
(F) misrepresent the patient 's obligation to pay for DME or exempt co - payment or deduction incurred by the patient.

Such fraudulent plans are emerging through the country, becoming emerging markets of organized crime and gang. In order to prevent criminal entrepreneurs from misusing the system, the institute commander of the Ministry of Health and Human Services will work with the US Attorney General and the team to create a task force called the HEAT team (Healthcare Fraud Prevention and Execution Action Team) I am assembling.

However, the most harmful DME fraud against health care systems in our country continues to be prioritized by larger, seemingly respected companies. Depending on the corporate structure, such companies often affect geographically large populations, but false allegations against Medicare and Medicaid are more likely to be detected than small, violent, criminal street-level projects It is even more difficult. Furthermore, it is very difficult to prove that there are criminal conscious companies and senior executives who deceive the Medicare and Medicaid systems. Therefore, civil lawsuit laws such as federal false claims laws are better equipped to combat such a large corporate DME fraudulent billing system. More importantly, the act of false billing includes a Quim (or whistleblower) clause that encourages insider to report fraud.

Under federal and several state false claims actions, internal alarmers can raise a lawsuit against a sealed DME company, possibly sharing 25% (possibly 30%) of the award there is. Prosecution about corporate fraud is courageous and the law rewards courage with certain protection. The false allegation regulation stipulates protection of internal whistle-blower litigation charged in the course of government investigation and the identity of internal whistleblowers.

In addition, Federal law prevents retaliation by obliging employees who have been fired illegally at the same seniority level to reinstate, awarded double repayment, interest, attorney's awards. Fees Over the past 200 years, taxpayer funds of more than $ 22 billion were collected under the False Claims Act. All the efforts and success of government and private claimants who thoroughly manage Medicare and Medicaid programs based on false allegation law is the only way that fraud can be effectively done knowledge People are to blow whistle.

© 2011 James F. Barger, Jr.

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