DME Scheme of Greed Knows No Bounds

Durable Medical EquipmentBy: Susan St. John

In yet another take-down of an illicit scheme to defraud the Medicare Program and ChampVA, as well as other insurers, Patsy Truglia has been sentenced to 15 years in federal prison. He has also had assets forfeited since these assets were acquired with money from his ill-gotten fraud scheme. In total, Mr. Truglia and his co-conspirators collected approximately $18.5 million from Medicare, ChampVA, and insurance using a scheme of telemarketing, telemedicine, and multiple DME providers or “store fronts.”

The scheme used telemarketers to collect beneficiaries personal and medical information to create orders for DME products such as knee, back, and wrist braces. These orders were then provided to telemedicine practitioners for signature – often without a valid telehealth communication. In essence, there was no attempt at having a practitioner exercise independent judgment as to the medical necessity of these DME products. Instead, these practitioners were paid for their signatures on the pre-filled order forms as part of the “scheme of greed.” From January 2018 to 2019, this scheme of greed resulted in approximately $12 million in payment to Truglia and his co-conspirators.Continue reading

Orthotics and Fitter Requirements – Clearing the Air for Medicare Enrolled DMEPOS Providers

dmepos orthotics

dmepos orthoticsBy: Michael Silverman

Also Available in Video Format!

With off-the-shelf knee and lumbar orthotics (HCPCS Code OR03) included in Medicare’s Round 2021 of Competitive Bidding (and thus ability to supply such devices to beneficiaries living in competitive bid areas limited to bid-winners), non bid-winning DMEPOS providers have been scrambling to find new revenue streams for their business models.

Many such providers are looking to continue providing orthotics – such as prefabricated (HCPCS Code OR02) or custom fabricated (HCPCS Code OR01) braces.

Unfortunately, a misunderstanding that could jeopardize Medicare billing privileges seems to be spreading. It pertains to DMEPOS provider personnel/fitter requirements to enable billing for such prefabricated or custom fabricated orthotics; allow me an opportunity to clear the air.Continue reading

DME Competitive Bidding Round 2021 – Now What?

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fhlf medicareBy: Michael Silverman

Medicare’s DMEPOS Competitive Bidding Round 2021 is now in full effect as of January 1, 2021. (See previous articles about what CBID Round 2021 is all about).

DME providers either participated in the process with hopes of being awarded a bid, or they abstained from doing so. Of those who participated, with Medicare’s recent bid winner announcements, bid winners were happy and bid losers, well not so much – as only those providers awarded a contract could service a Medicare Part B beneficiary for competitively bid product(s) for patients residing in competitive bid areas (“CBA”).

Now what? What are the options for the relationships between ‘winners’ and ‘losers’ in moving forward, if any? Let’s briefly discuss subcontracting.Continue reading

Obtaining & Maintaining Your DMEPOS Company’s PTAN & Accreditation

By: Michael Silverman

Becoming a DMEPOS provider enrolled with Medicare is no small feat or undertaking. Whether you’ve started the business from ‘scratch’ or purchased an existing entity, you need to ensure that investment is protected through active and ongoing compliance measures.

To that end, I recently hosted a webinar with Matthew Gruskin, Credentialing Director at Board of Certification (“BOC”) to discuss some of the steps necessary to do so.  A copy of our presentation is available here.

Becoming “accredited” is a necessary precursor to being a Medicare Part B DMEPOS provider, and BOC is one of only nine Medicare approved DMEPOS accreditation organizations. Whether it’s through BOC or one of the other eight Medicare approved accreditation organizations, a DMEPOS business’s initial receipt of accreditation is really just a ‘first step’, insofar as if that accreditation is not maintained a DMEPOS supplier will lose their Medicare Part B billing privileges. Medicare’s DMEPOS Supplier Standard #22 specifically requires all enrolled providers to be accredited to receive and retain billing privileges.

A DMEPOS supplier must continue to abide by both Medicare’s DMEPOS Supplier Standards (which the National Supplier Clearinghouse is tasked with enforcing) and its Quality Standards (which accreditation organizations gauge compliance by) in order to stay in its good graces. Accreditation organizations conduct unannounced on-site surveys at least every three years and suppliers must also revalidate their enrollment with Medicare’s National Supplier Clearinghouse every three years, which results in an unannounced Medicare on-site visit.Continue reading

Competitive Bid Checklist for DME Providers

By: Michael Silverman

Come January 2021, if a DME provider has not been awarded a CMS contract to supply a competitively bid item to a Medicare beneficiary that resides in a competitive bid area it will be unable to do so.

Suppliers looking to participate in the latest rendition of CMS’ Competitive Bidding Program need to act now to try and secure a bid.

Otherwise, once implemented, only DME providers that have won a bid for that specific item in that geographical bid area can service Medicare beneficiaries residing therein.

Here’s a ‘to-do’ list for providers looking to participate with a competitive bid, and the latest timeline updates from CMS.Continue reading

DMEPOS Round 2021 Competitive Bidding: Potential Pitfalls

competitive bidding

2021 competitive biddingBy: Matt Fischer

With the 2021 competitive bidding round on the horizon for durable medical equipment (DME) providers, both those that are established as well as those fairly new to the industry must take note of the potential pitfalls that may be encountered when competing to become a Medicare contract supplier.

The durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) competitive bidding program was first established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.  Under this program, DMEPOS suppliers submit bids (i.e. applications) and compete to furnish specific items in competitive bidding areas commonly referred to as CBAs.  Additionally, suppliers are not just bidding for the rights to a particular CBA but also for a single payment amount that will replace the current Medicare fee schedule payment.  The payment will be determined by using the bids submitted.  As of December 31, 2018, all contacts have expired.  As a result, there is currently a temporary gap period.  The upcoming bidding process is loaded with requirements.  Therefore, compliance with each requirement is crucial.  Here are a few pitfalls to watch out for: Continue reading

DME Provider Alert: Medicare Competitive Bidding is Back!

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Medicare Competitive BiddingBy: Michael Silverman

Not tomorrow, but relatively soon. And with a vengeance! We knew the current Competitive Bidding Program moratorium wouldn’t last forever, and that the floodgates that opened as of the first of this year would eventually be reined in.

Indeed, on March 7, 2019 the Centers for Medicare and Medicaid Services (“CMS”) announced a new round of Competitive Bidding, which will commence on January 1, 2021 and last through December 31, 2023.

The largest changes from previous rounds of Competitive Bidding that immediately stand out are:Continue reading

Marketing for DME & Pharmacy Providers: Know Your Subcontractor!

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marketing for dmeBy: Michael Silverman

Regulatory compliance is a mandatory investment for any healthcare business owner looking to stay out of serious and personal legal peril, let alone one hoping to keep their company viable.

Yet there is seemingly an onslaught of providers that blatantly run afoul of many of these regulations, knowingly or not, or those that believe they may have found a loophole.

Concerning the latter, there is an important mantra that such DME and pharmacy providers should remember and live by: “[W]hat a provider cannot do directly, it cannot do indirectly through an intermediary.”

Marketing for DME – What exactly am I talking about?

DME providers enrolled with CMS (should) know they cannot solicit or ‘cold call’ Medicare Part B beneficiaries, per the Federal Anti-Solicitation Statute, and that they cannot offer anything of value to a potential patient that could induce them to utilize them as a provider, in accordance with the Beneficiary Inducement Statute.Continue reading

DME Compliance Alert for Telehealth Doctors

By: Karina Gonzalez

Many DME suppliers purchase leads from marketing companies. The patients who respond to the marketing advertisements are generally not interested in travelling to their doctor’s office to obtain an order for braces, for example. This type of arrangement is seen often enough and so starts a potentially problematic arrangement with the DME company paying the marketing company.  The marketing company may then use some of these dollars to pay a telehealth company.  The telehealth company may then pay a telehealth physician for “telemedicine visit” with the patient. Ultimately, the telehealth/telemedicine physician issues and order for the braces or other supplies.The DME brace supplier then gets paid by Medicare Part C, or other healthcare plan for providing the supply to the patient.

The problem with this arrangement is that the sole source of the telehealth doctor’s reimbursement for the visit comes indirectly from the DME company.   Essentially, the DME supplier is paying the ordering physician through the marketing company for the visit with the patient.  This creates a prohibited kickback arrangement because the supplier is essentially paying the Teledoctor for the referral for braces. The telehealth company is acting as a virtual unregulated physician practice.  Providers engaged in this type of practice are not in compliance with either Federal or Florida law.