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Healthcare Defense: is my DME Business Safe

July 2, 2020

Modern medicine would be totally different were it not for durable medical equipment (DME). From wheelchairs to walkers – DME products are vital in almost every stage of medical care.

Because of the high demand for DME products, most of the federal government’s programs such as Medicaid, Medicare, the Department of Labor (DOL), and Tricare offer coverage for durable medical equipment.

The coverage includes the following products:

• Canes
• Blood sugar monitors
• Commode chairs
• Crutches
• Continuous passive motion devices
• Blood sugar test strips
• Hospital beds
• Oxygen equipment
• Suction pumps
• Patient lifts
• Walkers
• Traction equipment
• Nebulizer medication
• Wheelchairs

However, the federal government healthcare programs such as Medicaid only pay for what they term as “medically necessary” within a qualified program.

For businesses dealing with DME, knowing a device or product that is necessary for the context of the needs of a patient can be tricky. Most people depend on advice from doctors regarding durable medical equipment.

Questions concerning the necessity of medical equipment is where most DME businesses face challenges – when it comes to billing Medicaid, Tricare, DOL, and Medicaid. This is where they often run into trouble with federal government regulators.

The Office of the Inspector General (OIG), the Centre for Medicaid and Medicare Services (CMS), the Medicare Fraud Strike Force, the Department of Justice (DOJ) and several other federal government investigation agencies are constantly targeting DME companies for healthcare fraud investigations.

The good news is that there are several lawyers always on standby across the country to help businesses and business owners facing healthcare fraud investigations.

Most of these law firms have extensive experience in representing DME clients. Some of them have lawyers who have worked as healthcare fraud prosecutors in the Department of Justice.

It doesn’t matter what type of fraud charges have been leveled against your business, you will definitely find a lawyer who will represent and ensure that you get out of trouble.

Below are some of the common issues that can cause trouble for a DME business:

1. Compensation agreements that are against the law

Unlawful compensation can easily trigger healthcare fraud charges for a DME business. Most companies find themselves in trouble not because they want, but they sometimes don’t understand what constitutes a healthcare fraud.

This is common in telemedicine. According to the Anti-Kickback Statute, it is unlawful to receive, solicit, or pay to get a patient referral. This is where most DME businesses find themselves in trouble when they make payments to telemedicine companies and physicians as referral fees.

2. Absence of medical necessity

This is another factor that can cause serious issues for a DME business and its owners. During healthcare fraud investigations, investigators hold the view that medical necessity cannot be determined by orders from a doctor but from the language used in the billing guidelines of a program.

The strict guidelines are assumed not only to have more authority over the doctor’s instructions on the medical equipment but also differ from one program to another.

This means that when there are a lot of orders that don’t have a medical necessity, a durable medical equipment business may come under scrutiny for healthcare fraud.

3. Lack of adequate documentation

Considering the fact that DME businesses deal with patients from different federal government-funded programs, proper document maintenance is critical.

This may include documents such as correspondences with telemedicine companies, notes from doctors justifying order fulfilments for DME, legal agreements with medical practitioners, company billings, among others.

This is to make yourself ready when the federal government auditors come knocking at your door.

4. Issues to do with coding and billing

Even after fulfilling all the above requirements, it doesn’t mean you are now off the hook. Most DME businesses can find themselves in the middle of investigations due to billing errors. This is because of the complex federal government regulations on billing.

You have to be extra careful to ensure that you do not breach any of the stipulated regulations. Sometimes administrators can make honest errors when billing that can lead to culpability under the False Claims Act or under any federal fraud laws.

There’s no doubt that DME businesses play a significant role in the healthcare industry.

However, they can often run into trouble with federal government investigators for simple mistakes made by their administrators.



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