A guest column by the American College of Physicians, exclusive to KevinMD.com.
A couple of weeks ago, a television commercial caught my attention. It was an official-sounding announcement, a “national healthcare alert” that if you have Medicare, you might qualify for a knee brace “at little or no cost to you.” I found it interesting because a week earlier, a durable medical equipment (DME) company sent me a form to complete on behalf of one of my patients for a knee brace. The patient has a history of osteoarthritis of the knees, but was managing well despite her condition, and at her most recent visit a month earlier, she did not mention severe pain or limitation. I had my medical assistant confirm with the patient that she actually requested the brace. I declined to complete the form because I did not believe that she needed the brace (the patient agreed with my decision).
Last week, the same patient brought me a piece of paper on which she recorded twice-daily blood sugars for a few weeks. She told me that the company that provides the diabetic testing supplies told her that I ordered twice-daily monitoring and that she needed to complete the form for the test strips to be covered. The patient is a diet-controlled type 2 diabetic who does not need twice-daily monitoring and was not thrilled that she had to do it in order to complete the form.
A couple of years ago, forms for a heating pad, an ankle-foot orthosis, and a back brace were sent to me on behalf of a different patient. Again, I had not discussed any of these with the patient, and when my staff contacted him to question the requests, he said that the supplier told him that he could get these items for free but he added that he really didn’t need them.
DME-related fraud and abuse costs the Medicare and Medicaid program millions of dollars, if not more, annually. Some of the more flagrant cases, such as those involving motorized wheelchairs, make the headlines, but every day, more subtle instances of unscrupulous practices by some, not all, DME providers take place and physicians are often put in the middle.
A more frequent area of DME hijinks that I see involves diabetic testing supplies, as with the first patient. Not only do I come across forms that overstate the frequency of testing (and remind me that my medical record must support the frequency that I did not recommend), but I often receive diabetic testing supply forms from multiple companies on the same patient within months of one another.
I can think of several reasons for this pernicious problem that costs taxpayers and beneficiaries. Naïve patients are swayed easily by sales tactics. Others find the ability to get something for nothing appealing, especially given the money that they paid into the system over many years. Physicians and other providers are often too busy to perform due diligence when they receive requests from patients or DME suppliers.
CMS is taking action to reduce DME fraud and abuse. Among them are increased requirements for documentation and a new requirement that a face-to-face visit occur in conjunction with the prescription of certain DME items (explained in ACP’s summary of the 2013 Medicare Fee Schedule). The face-to-face requirement has been delayed until sometime later this year.
Physicians and patients can do their part to prevent DME fraud and abuse. It is standard practice in my office for my medical assistant to call any patient for whom we receive a DME form to verify that the patient knows about it and to find out who originated the request. That may seem like an added hassle (and it is), but it’s less work than filling out a form that doesn’t need to be filled out for DME that isn’t necessary. You can report suspicious activity to Medicare via a special e-mail address or by completing a form. That, too, takes time, but it provides a small amount of gratification. A more basic measure is to read everything that you are asked to sign and don’t prescribe something that a patient does not need.
Patients should keep in mind that not everything that Medicare covers is medically necessary, just as not everything that is medically necessary is covered by Medicare. AARP has a helpful guide for recognizing and reporting DME fraud.
It is unfortunate that physicians have to act as police for the Medicare program, but at the same time, it is outrageous that physicians and their patients are being taken advantage of by dishonest DME suppliers.
Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.