January 7,1999 Ben St. John (202) 619-1028
PHYSICIAN DILIGENCE URGED IN ORDERING
HOME CARE, DURABLE MEDICAL EQUIPMENT
Inspector General June Gibbs Brown of the Department of Health and Human Services
(DHHS)
today urged the Nation's physicians to take care to authorize only necessary medical services,
equipment and supplies for Medicare beneficiaries.
In a Special Fraud Alert issued today for publication next week in the Federal Register,
Inspector
General Brown expressed concern that some physicians are inappropriately ordering home health
care and durable medical equipment and supplies for Medicare patients. Under the Medicare
program, a physician prescribing home health care or durable medical equipment, such as
hospital
beds, wheelchairs and oxygen delivery systems, must certify that the services or items are
medically necessary and that the beneficiary meets the requirements to qualify for the benefit.
"This Fraud Alert is intended to both educate and remind physicians of the legal and
programmatic significance of certifications they make in connection with the ordering of home
health care and durable medical equipment for their Medicare patients," Inspector General Brown
said. "While physician fraud in this area is infrequent, physician laxity in reviewing and
completing
certifications of medical necessity is a problem that can contribute to fraudulent and abusive
practices by unscrupulous suppliers and home health providers."
Recent Office of Inspector General (OIG) audits have shown that physicians sometimes order
home health care without assessing the patients' need for it and authorize unnecessary durable
medical equipment. In one case, the OIG found that to qualify patients for home health services,
a physician signed a number of forms provided by a home health agency that falsely represented
that the patients required skilled nursing services. In another case, a physician, at the urging of a
durable medical equipment supplier, signed a stack of certificates which were later completed by
the supplier with false information and submitted to Medicare along with fraudulent claims for
durable medical equipment. In a third case, a physician accepted $50 to $400 in kickbacks from
a
medical equipment supplier for each prescription the physician signed for certain equipment.
"A physician is not personally liable for erroneous claims due to mistakes, inadvertence, or
simple
negligence," Inspector General Brown noted. "However," she added, "knowingly signing a false
or misleading certification or signing with reckless disregard for the truth can lead to serious
criminal, civil, and administrative penalties." Offenders may be liable for making false or
misleading certifications even if they did not receive any financial or other benefit from providers
or suppliers.
Physicians are cautioned in the Fraud Alert (1) not to prescribe services and items as a
courtesy to
a patient, service provider, or medical equipment supplier, without first making a determination
of
medical necessity, (2) not to knowingly or recklessly sign false or misleading medical
certifications, and (3) not to accept kickbacks in return for their signature.
Before ordering home health care for a Medicare patient, physicians are reminded that they
must
certify that the patient is homebound, under physician care, and in need of intermittent skilled
nursing care, physical therapy or speech therapy. They also must establish and periodically
review
a plan of care for the patient. In ordering durable medical equipment, physicians are required to
submit to the supplier a written order or prescription that is dated, signed, and lists the patient's
name, address, diagnosis, the item needed, the length of time it is expected to be needed, and the
start date, if appropriate. For certain items or supplies, including supplies provided on a periodic
basis and drugs, additional information may be required. Durable medical equipment suppliers
that submit bills to Medicare are required to maintain the physician's original written order or
prescription in their files.
The Fraud Alert urges physicians and their staff to report any suspicious activity in connection with the solicitation or completion of certifications to the OIG, which is responsible for protecting the integrity of Medicare and other DHHS programs. The OIG actively investigates fraudulent schemes and, when appropriate, issues Special Fraud Alerts that identify segments of the health care industry that are particularly vulnerable to abuse.
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