Here are the key rules for home health compliance
Here are the key rules for home health compliance
The hows and wherefores of avoiding trouble
Medicare will only pay for durable medical equipment (DME) like hospital beds, wheelchairs, and oxygen delivery systems for home use — and the medical supplies that are necessary for the effective use of DME, like surgical dressings, catheters, and ostomy bags — if it has been first ordered or prescribed by a physician. To be official, 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. Physicians should not sign any order or prescription unless it contains:
• beneficiary’s name and full address;
• date on which the physician signed the prescription or order;
• description of the items needed;
• start date of the order (if appropriate);
• 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 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 the duration of infusion and concentration (if applicable) should be included.
Medicare further requires claims for payment for certain kinds of DME to be accompanied by a certificate of medical necessity (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 certificate containing the treating physician’s original signature and date on file.
A certificate of medical necessity generally has four sections:
• Section A contains general information on the patient, supplier, and physician. Section A may be completed by the supplier.
• Section B contains the medical necessity justification for DME. This cannot be filled out by the supplier. Section B must be completed by the physician, a nonphysician clinician involved in the care of the patient, or a physician employee. If the physician did not personally complete section B, the name of the person who did complete section B and his or her title and employer must be specified.
• Section C contains a description of the equipment and its cost. Section C is completed by the supplier.
• Section D is the treating physician’s attestation and signature, which certifies that the physician has reviewed sections A, B, and C of the CMN and that the information in section B is true, accurate, and complete. Section D must be signed by the treating physician. Signature stamps and date stamps are not acceptable.
By signing the certificate of medical necessity, the physician represents that:
• he or she is the patient’s treating physician and the information regarding the physician’s address and unique physician identification number is correct;
• the entire CMN, including the sections filled out by the supplier, was completed prior to the physician’s signature;
• the information in section B relating to medical necessity is true, accurate, and complete to the best of the physician’s knowledge.
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:
• criminal prosecution;
• fines as high as $10,000 per false claim plus treble damages;
• administrative sanctions, including exclusion from participation in federal health care programs, withholding or recovery of payments, and loss of license or disciplinary actions by state regulatory agencies.
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