OFFICE OF INSPECTOR GENERAL
SPECIAL FRAUD ALERT
PHYSICIAN LIABILITY FOR CERTIFICATIONS IN THE PROVISION OF MEDICAL EQUIPMENT AND SUPPLIES AND HOME HEALTH SERVICES
The Office of Inspector General (OIG) was established at the Department of Health and Human Services by Congress in 1976 to identify and eliminate fraud, waste, and abuse in the Department's programs and to promote efficiency and economy in departmental operations. The OIG carries out this mission through a nationwide program of audits, inspections, and investigations.
To reduce fraud and abuse in the Federal health care programs, including Medicare and Medicaid, the OIG actively investigates fraudulent schemes that obtain money from these programs and, when appropriate, issues Special Fraud Alerts that identify segments of the health care industry that are particularly vulnerable to abuse. Copies of all OIG Special Fraud Alerts are available on the internet at:
We are issuing this Fraud Alert because physicians may not appreciate the legal and programmatic significance of certifications they make in connection with the ordering of certain items and services for their Medicare patients. While the OIG believes that the actual incidence of physicians' intentionally submitting false or misleading certifications of medical necessity for durable medical equipment or home health care is relatively infrequent, physician laxity in reviewing and completing these certifications contributes to fraudulent and abusive practices by unscrupulous suppliers and home health providers. We urge physicians and their staff to report any suspicious activity in connection with the solicitation or completion of certifications to the OIG.
Physicians should also be aware that they are subject to substantial criminal,
civil, and administrative penalties if they sign a certification knowing that
the information relating to medical necessity is false, or with reckless disregard
as to the truth of the information being submitted. While a physician's signature
on a false or misleading certification made through mistake, simple negligence,
or inadvertence will not result in personal liability, the physician may unwittingly
be facilitating the perpetration of fraud on Medicare by suppliers or providers.
Accordingly, we urge all physicians to review and familiarize themselves with
the information in this Fraud Alert. If a physician has any questions
as to the application of these requirements to specific facts, the physician
should contact the appropriate Medicare Fiscal Intermediary or Carrier.
The Medicare program only pays for health care services that are medically necessary. In determining what services are medically necessary, Medicare primarily relies on the professional judgment of the beneficiary's treating physician, since he or she knows the patient's history and makes critical decisions, such as admitting the patient to the hospital; ordering tests, drugs, and treatments; and determining the length of treatment. In other words, the physician has a key role in determining both the medical need for, and utilization of, many health care services, including those furnished and billed by other providers and suppliers.
Congress has conditioned payment for many Medicare items and services on a certification signed by a physician attesting that the item or service is medically necessary. For example, physicians are routinely required to certify to the medical necessity for any service for which they submit bills to the Medicare program.
Physicians also are involved in attesting to medical necessity when ordering services or supplies that must be billed and provided by an independent supplier or provider. Medicare requires physicians to certify to the medical necessity for many of these items and services through prescriptions, orders, or, in certain specific circumstances, Certificates of Medical Necessity (CMNs). These documentation requirements substantiate that the physician has reviewed the patient's condition and has determined that services or supplies are medically necessary.
Two areas where the documentation of medical necessity by physician certification plays a key role are (i) home health services and (ii) durable medical equipment (DME). Through various OIG audits, we have discovered that physicians sometimes fail to discharge their responsibility to assess their patients' conditions and need for home health care. Similarly, the OIG has found numerous examples of physicians who have ordered DME or signed CMNs for DME without reviewing the medical necessity for the item or even knowing the patient.
PHYSICIAN CERTIFICATION FOR HOME HEALTH SERVICES
Medicare will pay a Medicare-certified home health agency for home health care provided under a physician's plan of care to a patient confined to the home. Covered services may include skilled nursing services, home health aide services, physical and occupational therapy and speech language pathology, medical social services, medical supplies (other than drugs and biologicals), and DME.
As a condition for payment, Medicare requires a patient's treating physician to certify initially and recertify at least every 62 days (2 months) that:
The physician must order the home health services, either orally or in writing,
prior to the services being furnished. The physician certification must be obtained
at the time the plan of treatment is established or as soon thereafter as possible.
The physician certification must be signed and dated prior to the submission
of the claim to Medicare. If a physician has any questions as to the application
of these requirements to specific facts, the physician should contact the appropriate
Medicare Fiscal Intermediary or Carrier.
DME is equipment that can withstand repeated use, is primarily used for a medical purpose, and is not generally used in the absence of illness or injury. Examples include hospital beds, wheelchairs, and oxygen delivery systems. Medicare will cover medical supplies that are necessary for the effective use of DME, as well as surgical dressings, catheters, and ostomy bags. However, Medicare will only cover DME and supplies that have been ordered or prescribed by a physician. The order or prescription must be personally signed and dated by the patient's treating physician.
DME suppliers that submit bills to Medicare are required to maintain the physician's original written order or prescription in their files. The order or prescription must include:
o the beneficiary's name and full address;
o the physician's signature;
o the date the physician signed the prescription or order;
o a description of the items needed;
o the start date of the order (if appropriate); and
o the diagnosis (if required by Medicare program policies) and a realistic estimate of the total length of time the equipment will be needed (in months or years).
For certain items or supplies, including supplies provided on a periodic basis and drugs, additional information may be required. For supplies provided on a periodic basis, appropriate information on the quantity used, the frequency of change, and the duration of need should be included. If drugs are included in the order, the dosage, frequency of administration, and, if applicable, the duration of infusion and concentration should be included.
Medicare further requires claims for payment for certain kinds of DME to be accompanied by a CMN signed by a treating physician (unless the DME is prescribed as part of a plan of care for home health services). When a CMN is required, the provider or supplier must keep the CMN containing the treating physician's original signature and date on file.
Generally, a CMN has four sections:
By signing the CMN, the physician represents that:
o he or she is the patient's treating physician and the information regarding
the physician's address and unique physician identification number (UPIN) is
o the entire CMN, including the sections filled out by the supplier, was completed prior to the physician's signature; and
o the information in section B relating to medical necessity is true, accurate, and complete to the best of the physician's knowledge.
IMPROPER PHYSICIAN CERTIFICATIONS FOSTER FRAUD
Unscrupulous suppliers and providers may steer physicians into signing or authorizing improper certifications of medical necessity. In some instances, the certification forms or statements are completed by DME suppliers or home health agencies and presented to the physician, who then signs the forms without verifying the actual need for the items or services. In many cases, the physician may obtain no personal benefit when signing these unverified orders and is only accommodating the supplier or provider. While a physician's signature on a false or misleading certification made through mistake, simple negligence, or inadvertence will not result in personal liability, the physician may unwittingly be facilitating the perpetration of fraud on Medicare by suppliers or providers. When the physician knows the information is false or acts with reckless disregard as to the truth of the statement, such physician risks criminal, civil, and administrative penalties.
Sometimes, a physician may receive compensation in exchange for his or her signature. Compensation can take the form of cash payments, free goods, or any other thing of value. Such cases may trigger additional criminal and civil penalties under the anti-kickback statute.
The following are examples of inappropriate certifications uncovered by the OIG in the course of its investigations of fraud in the provision of home health services and medical equipment and supplies:
A physician is not personally liable for erroneous claims due to mistakes, inadvertence, or simple negligence. However, knowingly signing a false or misleading certification or signing with reckless disregard for the truth can lead to serious criminal, civil, and administrative penalties including:
Physicians may violate these laws when, for example:
Even if they do not receive any financial or other benefit from providers or suppliers, physicians may be liable for making false or misleading certifications.
If you have information about physicians, home health agencies, or medical equipment and supply companies engaging in any of the activities described above, contact any of the regional offices of the Office of Investigations of the Office of Inspector General, U.S. Department of Health and Human Services, at the following locations:
|Field Offices||States Served||Telephone|
|Boston||MA, VT ,NH, ME, RI, CT||617-565-2664|
|New York||NY, NJ, PR, VI||212-264-1691|
|Philadelphia||PA, MD, DE, WV, VA, DC||215-861-4586|
|Atlanta||GA, KY, NC, SC, FL, TN, AL, MS||404-562-7603|
|Chicago||IL, MN, WI, MI, IN, OH, IA, MO||312-353-2740|
|Dallas||TX, NM, OK, AR, LA, CO, UT, WY, MT, ND, SD, NE, KS||214-767-8406|
|Los Angeles||AZ, NV, So. CA||714-246-8302|
|San Francisco||No. CA, AK, HI, OR, ID, WA||415-437-7961|