Fraud & Abuse:
Don't Let Erroneous DMERC Education Letters Slide
Published on Mon Apr 04, 2005
Ignored warnings could come back to bite you later. If your durable medical equipment business gets a letter from your regional carrier warning you about potential fraud, make sure you read it carefully.
Some of those letters contain incorrect information - and if you fail to address the letter promptly, you could end up in trouble down the road, warns Seth Lundy, attorney with Fulbright & Jaworski's Washington office.
Since launching its crackdown on DME fraud, the Centers for Medicare & Medicaid Services through its DME regional carriers has been sending warning letters to alert suppliers to potentially fraudulent practices.
The letters are an outgrowth of Operation Wheeler Dealer, an anti-fraud enforcement initiative launched by CMS in 2003. Some letters sent by the DMERCs after claims reviews have been "off the mark," Lundy told a panel at a recent American Health Lawyers Association meeting.
Some of the problematic letters address beneficiary contact, Lundy tells Eli.
"They will say, for example, that the supplier is required to contact the beneficiary no more than seven days in advance," he says. "But that's not what the Program Integrity Manual says. It sets seven days as a guidance and uses the term 'approximately seven days in advance.'"
In reality, seven days may not be sufficient in many cases for mail-order suppliers to contact the beneficiary, process the order and ship it out quickly enough that the beneficiary does not run out of supplies.
Some letters have also offered questionable information on proof of delivery, stating that program integrity units will not accept proof-of-delivery systems that do in fact comply with the PIM requirements.
Take action: If you get a letter with questionable information, don't just file it away, Lundy urges.
"My suggestion to suppliers has been to actively respond to the DMERC or the fraud control unit and let them know that there's a disagreement in the education," he says.
By putting objections to the education in writing, suppliers protect themselves from having a DMERC or PI official tell them that they've been educated about a particular practice but they continue to do it, which means they're committing fraud.
At this point, Lundy knows of no effort underway to tackle the problem other than on a letter-by-letter, issue-by-issue basis.
"Each topic that they're wrong on probably needs to be addressed separately unless we get a large enough volume that we can go to CMS' central office and say, 'Your contractors are way off base here on many, many issues - you need to find a better way to do education,'" he says.
