The high cost of “free,” unnecessary medical equipment

The high cost of free, unnecessary medical equipmentA guest column by the American College of Physicians, exclusive to

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.

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  • Shane Irving

    Thank you for this article… I have heard this from a number of providers and agree that the ads and sales techniques are very dishonest to say the least.

  • southerndoc1

    “It is unfortunate that physicians have to act as police for the Medicare program”

    Nope. It’s not in my job description to be an unpaid policeman for Medicare (or any other insurer), and for me to take on that role would be a violation of my professional ethics.

    When I get one of these forms, I have the patient come in, I transcribe their answers to any questions asked, I cross out, sign and date any attestation that what I am writing is the truth and substitute “as per patient,” and charge an office visit.

    There are many ways to fix the DME mess, but dumping it on the docs isn’t one of them.

    • rtpinfla

      I do not fill out these forms unless I believe it is medically necessary and don’t consider it policing for Medicare fraud, simply doing what is medically correct for the patient.
      Eventually, Medicare will get sick of paying for this and we will spend more time filling out even more forms to justify equipment for those that actually do need it.
      One way or the other, we will inevitable be involved.

      • Dr. Drake Ramoray

        I’m in your camp as I once had a patient continue to ask me to fill out paperwork for disability because of diabetes. They didn’t qualify for disability (no complications related to diabetes) and their diabetes didn’t even interfere with their current job in a meaningful way. I actually finally filled it out with the required letter, all about how he didn’t need to be on disability. (Yes I told the patient ahead of time how the form would be filled out, but he just wanted me to fill out the G$d D#$n form.)

        That being said. Would your opinion on this subject change if your reimbursement is tied to satisfaction surveys? How many physicians do you think that would sway? I have considered this question for narcotic prescriptions as well, although I’m not directly involved in the prescribing of those meds.

        The diabetic testing supplies is a fairly non-issue for most Endos as most of us have gotten in the habit of stating how many times a patient checks and why they need to do so in our patient notes. We still get requests occasionally but our MA’s are able to fill out the forms based on our most recent clinic notes when this does happen. I once had a company request I write an individualized letter for each patient on why they had to test the number of times they do and I steered my patients away from that supply company.

        • Suzi Q 38

          Good for you.
          Some people are healthier than me, and get disability.
          I had severe spinal stenosis, and have limited walking, sitting, and standing ability.
          It literally hurts to do any one thing listed above for very long.
          I still go to my classroom and teach everyday for 4-5 hours.
          I have friends who are walking just fine, and their physicians arrange for a handicapped parking permit. I feel like getting one, but I get off my rear end and walk slowly and deliberately, or wait for a parking shuttle to give me a ride.

          I have a friend who is fine and meeting her friends for lunch and shopping, but got her doctor to write her off on disability.
          She gets a check every month since the age of about 45 and I am still working.

          I guess I could ask her who HER doctor is,
          if I wanted to get a free check for not working.

          I agree that many people should be placed on disability, but SHEESH.
          I work part time and am paid for part time.
          If they are disabled, can’t some work somewhere part time?

  • LeoHolmMD

    HHS/Medicare could do plenty to prevent fraud…for instance not purchasing or promoting it. Those DME companies get patient information from Medicare in clear disregard for their privacy. Another unfortunate side effect from the thug culture who invented every perverse incentive medicine has had to endure.

    • Deceased MD

      Brillaint Dr. Holm! You’ve hit it on the head. THese DME companies are hounding pts with disabilities to get “free” stuff. Just looking on tv it is disgusting. And medicare absolutely “promotes” the corruption. And the more that pt info is not protected in this perverse way( that is the correct term), the more DME co.’s are fed. Perverse is the word!

      • querywoman

        Most of them don’t collect patient copays and bill for a higher proportion to get more on their 80% copay. A lot of doctors don’t collect Medicare 20% copays either.
        Technically, that’s illegal, but it’s one of those things that’s mostly ignored.
        If Medicare went after those companies on waiving copays, it would help, but then they would have to go after the doctors too.
        They don’t have enough employees to do that.

  • PrimaryCareDoc

    One of the latest issues I’ve encountered is oxygen supply companies sending me already filled out order sheets to check overnight O2 sats on all my patients with nebulizers.

    Don’t even get me started on the scooters….

    • Deceased MD

      Disgusting. These guys make ambulance chaser look like honest lawyers making a living.

      • querywoman

        Lawyers? My mother and I had a car accident on the interstate. A big truck hit is, and we did 360 spins across the interstate on the other side, till suddenly we were safe on the access road on the other side.
        The car had some scrapes and a flat tire.
        We did get an ambulance, but neither of us needed medical attention.
        Wreckers arrived. One of us told him to let him tow us because he beat the other guy.
        A real ambulance chaser!

        All businesses are about money!

        • Deceased MD

          good sense of humour. hope you are ok QW. My disqus is not working properly. I think I am missing messages? anyway glad I caught yours.

          • querywoman

            I notice I’m not getting my routine thumbs down when talking about the blood glucometer scams.

            We were fine after the accident. It was the ultimate roller coaster ride. My mother was driving, since I dislike driving. The truck driver who hit us said he couldn’t believe it when we walked out of the car on the other side of the interstate.
            I got about $3000 for the accident.

  • querywoman

    The relatively inexpensive blood glucometers exemplify this. They were $70 when they first came out. They may still cost a few bucks to manufacture, but you can get them free.
    I like a Breeze 2 Ascencia meter. Only once did I pay for it with Medicare, and Medicare paid 80% of about $75.
    I hate it when my meter breaks. I now have three Ascencia meters that cost me about $5.99 each, direct pay, at Walgreens.
    Someone always wants to send a diabetic a free meter.

    • PrimaryCareDoc

      Right. And then charge them an arm and a leg for test strips!

      • querywoman

        I recently got a diabetes-related solicitation call from someone who spoke horrible English. Because I’d recently been in the hospital with pneumonia, I thought maybe it was a followup call related to the illness.
        The guy said something about Medicaid and asked me how many times a day I checked. I answered him, though I do get Medicare, not Medicaid.
        Then I said I wanted someone who spoke English. He said, “I speak English.” I said, “Not very well.” He kept saying something about Medicaid.
        I then realized he was a solicitor, and told him so. I also told him not to call me again.
        Watch out for these solicitors! They were really scraping the bottom of the barrel when they hired this guy!
        The free meters aren’t in the very expensive class like a Hoveround, but they are an excellent example of the techniques the medical solicitors use.
        Yes, they want the strip income. Wonder how little it costs to manufacture those tiny special strips?

        • Yul Ejnes, MD, MACP

          To make things even worse, there appears to be a “black market” for test strips – . I don’t know how widespread it is, but it is another example of waste.

          • querywoman

            Such an easy thing to feed a secondary and third markets.
            people sell them on ebay. They also sell insulin, which most don’t realize, with the exception of a couple types, is a nonprescription drug.
            I have known people who routinely let a friend order strips on the friend’s insurance.

            I order my Breeze strips from a company that is one of Medicare’s approved mail order suppliers now. I was surprised at how little the full cost is.
            No one will let us know how profitable the strips are, especially the brand names,
            My nearest Family Dollar has a $10 Rexall meter and I think, 50 test strips, for $10!!!!!!!!!!!

          • querywoman

            Good article! Thanks! I quibble one part: most expired strips are fine. But, when I use expired strips, I also compare with a fresh strip. Many people won’t do that.
            This is a real gold mine: better than alcohol, drugs, or tobacco. Perhaps less profitable!

    • Suzi Q 38

      I had a huge banana box full of free Breeze 2 meters.
      Why? Walgreens was selling them for about $5.00 each, and there was a coupon for $5.00. I got them all for free.
      I kept about 3 for myself, then gave the rest to nurses who worked at FREE clinics.
      The meters are free because the test strips are really expensive.

      • querywoman

        Yup! I saw a bucnh at a thrift store one night for a little over two bucks a piece. Wish I’d had some money that night.
        I think the same foreign-sounding solicitor called me yesterday. He asked me had I had surgery, and I said yes. He told me I was entitled to compensation.
        I’ve not haad any surgery since 2003.
        He said he was with “State Medical.” He woulcn’t give me the address. I told him I was not eliigible for any comepnsation, that he was a solicitor, and I watned his address.
        Then the line went dead.

        • querywoman

          What I would give to get rid of this solicitor. He sounds dangerous the way he comes on, trying to trick people into getting their info.
          I’m not sure his English is good enough to sell anything, though.
          I use Google Voice, and his number shows as “private,” no caller id. I blocked the last time he called on Google Voice, even without even showing his phone number.

  • maggiebea

    Another culprit is Medicare itself, when it pays for a ‘package deal’ without reference to the actual patient’s specific actual needs. A new hospice patient already on Medicare will probably get: a hospital bed whether needed or not; a walker (even though she already has two); a rented wheelchair even though she owns one and keeps it in the attic because she’s not using a chair. …and so on. When we tried to take only what we needed we were told Medicare would pay for the whole package, or none of it.

  • querywoman

    So many signup deals on the net offer a, “free blood sugar meter.” Then they want all your insurance details, so they can start billing for strips and sending them out.
    This is how many people get hooked.
    Over the years, I have accumulated so many meters without getting any of these free meters in the mail. The manufacturers constantly update them, then the strips are obsolete.
    I prefer an Ascencia Breeze. I get a wheel of 10 strips. I hate strip loading. Bayer is always trying to get me to update to a newer one with a bunch of computer keerap. I don’t want it. I guess they charge a little extra for the newest strips.
    I recently was waiting for a mail order delivery and out of strips. I got some cortisone shots at my derm, so I needed to monitor my blood sugar.
    I went to Walgreens, got one of their newest meters and 50 strips for about $25. Then I got perhaps a $12 rebate in the mail. I could get 100 strips for their meter online for about $100.
    In a free country, could we make advertising free blood sugar meters in the mail illegal? They are not truly free; they want your insurance billing info.

  • querywoman

    Would love that! One doctor wrote here about people who have multiple requests for supplies from different companies in one month and who ask him to fill out forms. They’ve been signing up for stuff.
    A glucometer is totally worthless without the strips!

  • Curtiss Mull M.D.

    I am of the same concerns. Once several years ago ,I had a rheumatoid patient who apparently saw some dme co and was told she needed a paraffin bath touse at home. I got a request from them for a prescription, which I refused to sign as it is of no value in treatment. I happened to be attending a meeting in Washington and at a discussion on Medicare fraud, I spoke to the then inspector General, who gave me his card and told me to send all the info to him. As it turned out this was a company which was known to the fraud unit and was put out of business within a month. Sometimes government works. As physicians,we need to keep. Reporting fraud.

    • Deceased MD

      Just stay home and watch tv commercials. They’re too numerous to count.

    • Yul Ejnes, MD, MACP

      There are ways of reporting these companies to CMS (I posted links in the article); however, what little satisfaction comes from doing one’s part is offset by the slow response to the posting of a report. I did not hear back from CMS for over a month when I used the online form. I don’t know if this is typical, but it doesn’t encourage reporting suspected fraud.

  • swatdoc

    We have a policy in place with a form letter that tells the faxing party we no longer approve these items without a face to face and documentation that the patient really needs the product. The letter informs the company to send the form to the patient and have them make an appointment to bring in the form and discuss with the doctor. Also informing them that any further faxed requests will end up in the shred box. Over the last 24 months it has dramatically reduced the faxes. We also do not do motorized chairs just too much paperwork I suggest they speak with their ortho doc.

    • Yul Ejnes, MD, MACP

      Yours seems like a good system. As I noted in the article, for some DME, Medicare will soon require the face-to-face, not unlike the requirement for home health care. (And they will pay for that visit as a stand-alone.) As with much of this, a mixed bag – it may reduce inappropriate use but it adds to the hassles of the physician office (paying us doesn’t make the hassle go away).

  • Suzi Q 38

    This type of “abuse” drives me nuts.
    I see the ads on television.
    I ignore them, but I am sure others call the 800 number provided on the TV screen.
    It is not just ads on television.
    There is another ad that advertises a motorized wheelchair.
    All we have to do is call the 800#, and they will do the rest.

    For me, it has lately been with physical Therapy.
    The physical therapists assume that you will want or need twice a week sessions at their hospital. I like to go once a week, and only if I feel that what they have planned for me has merit.
    Greeting me, then having me ride a recumbent bike for 10 or 15 minutes, followed by some stretching that I can do by myself or at home is not a good use for my insurance “dollars.” The finale is usually a bag of ice for the last 15 to 20 minutes. Not impressive.

    My neurologist chastised me for not going to the PT.
    I told her that I would gladly do so if she had a plan for my visits at the PT. She said that she wanted me to walk a little better, without my slight limp. I told her that as soon as I find a PT therapist that is really good, I would be happy to oblige. My PT visits are charged to my PPO insurance for about $300.00 a 45 minute visit (15 minutes of which is an ice bag).
    I can do whatever they have been doing for me at the gym, which costs me about $15.00 a month.

    I will not allow this type of insurance abuse to continue with my insurance.

    • Yul Ejnes, MD, MACP

      Thank you for your post – this is a problem that all of us need to solve together – patients should be aware of the potential for abuse and understand that, like medications, even if DME is covered, it must also be medically necessary; physicians should not sign for DME without assessing if it’s truly needed; and insurers (including CMS) should be more vigilant.

  • querywoman

    It’s possible that the free blood meters are even more profitable than the scooters, since compliant diabetics use a lot of them. Within a year, the company doing the strips could get a lot of profit.
    Big electronic companies like Frys don’t have much of a profit margin on stuff like computers and TV’s. They make most of their money on the little, like $10 cables that you can get at a dollar store.

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