New reason for doctor house calls: Feds tighten rules on physician role
New reason for doctor house calls: Feds tighten rules on physician role
OIG warns of durable goods crackdown
Turning up the anti-fraud heat a notch higher, the U.S. Department of Health and Human Services has issued a special fraud alert reminding physicians of their legal responsibility to authorize only necessary durable medical equipment and home health services for Medicare beneficiaries.
Given the fact that the Office of the Inspector General (OIG) has publicly red-flagged the issue, physicians and their billing offices should take extra care in ensuring they follow established procedures when filing home health and DME-related claims.
In a Jan. 7 alert, Inspector General June Gibbs Brown expressed concern that "some physicians are inappropriately ordering home health care and durable medical equipment and supplies for Medicare patients."
Under Medicare, a physician prescribing home health care or dura ble 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.
Brown says she believes "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." However, recent OIG audits have uncovered a certain "physician laxity in reviewing and completing these certifications," which has aided "fraudulent and abusive practices by unscrupulous suppliers and home health providers," she says.
OIG audits, for instance, have revealed instances of physicians signing forms provided by home health agencies that falsely represent patients as needing skilled nursing services to qualify them for home health services, the OIG says.
In another case, a physician, at the urging of a durable medical equipment supplier, simply signed a stack of blank certificates of medical necessity that the supplier later completed with false information and submitted to Medicare along with fraudulent claims for durable medical equipment. There also have been cases of physicians accepting kickbacks of $50 to $400 from medical equipment suppliers 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," Brown notes. "However," she adds, "knowingly signing a false or misleading certification or signing with reckless disregard for the truth can lead to serious criminal, civil, and administrative penalties." Moreover, 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.
The fraud alert specifically cautions physicians:
• 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;
• not to sign false or misleading medical certifications knowingly or recklessly;
• not to accept kickbacks in return for their signature.
According to OIG spokesman Ben St. John, there are several key steps physicians must go through to properly document the need for home health care. "Before ordering home health care for a Medicare patient, physicians must certify that the patient is homebound, under physician care, and in need of intermittent skilled nursing care, physical therapy, or speech therapy. And they must also establish and periodically review a plan of care for the patient," says St. John.
When ordering durable medical equipment, physicians are required to give the supplier a written order or prescription that is dated and 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.
Physician certification rules
According to rules established by the Health Care Financing Administration (HCFA), 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 such services as skilled nursing services, home health aide services, physical and occupational therapy, speech-language pathology, medical social services, medical supplies (other than drugs and biologicals), and durable medical equipment.
As a condition for payment, Medicare requires a patient’s treating physician to certify initially and recertify at least every 62 days that:
• The patient is confined to the home.
• The patient currently requires or has needed:
— intermittent skilled nursing care,
— speech or physical therapy or speech- language pathology services,
— occupational therapy or a continued need for occupational therapy.
• A plan of care has been established and periodically reviewed by the physician.
• The services are (were) furnished while the patient is (was) under the care of a physician.
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 when the plan of treatment is established or as soon thereafter as possible. This physician certification must be signed and dated prior to the submission of the claim to Medicare. If there are any questions about how these rules apply to specific situations, the physician should contact the appropriate Medicare fiscal intermediary or carrier.
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