How to Curtail Some Medicare Fraud

Vol. 20 •Issue 22 • Page 27
How to Curtail Some Medicare Fraud

As a respiratory therapist with 29 years of experience, I am aware of many occurrences of Medicare fraud and abuse and have concluded that due to them, it is possible there will be no Medicare benefits in the near future.

I would like to share some of the typical scenarios that lead to such fraud and suggest ways to circumvent it.

The most repeated abuse probably centers on qualifying patients for home oxygen therapy. Typically what happens follows this line: A physician will ask a DME employee to visit a patient in his home and do a spot check pulse oximetry reading on the patient while at rest and during exercise to see whether that patient will qualify for home oxygen.

Most DME staff will do that. However, DME employees are not allowed to use their own tests to qualify a patient for oxygen. To qualify for reimbursement, the patient must be tested by a medical professional not associated with a DME. In fact, the Medicare Manual specifically states that qualifying pulse oximetry results cannot be accepted from DME suppliers. DME staff can basically advise a physician on the matter only.

That doesn’t mean much to some caregivers. Some DME operators will go so far as to say they do not care where the results come from; they care only about getting a new oxygen patient.

Caregivers circumvent the rules as well, qualifying patients on the basis of a telephone conversation or on the basis of results from testing done at health fairs.

Shortcuts at Work

DME suppliers are always thinking of resourceful ways in obtaining qualifying test results.

Now they can purchase a pulse oximetry unit from their vendor of choice.

These will typically be the same vendors from whom they buy their concentrators, liquid bases and supplies. When overnight nocturnal pulse oximetry is performed on a potential oxygen patient, the DME supplier then either mails the oximetry results or downloads the test directly to the vendor.

The vendor, in turn, can compile the test results on letterhead and fax the results to the supplier. The supplier then faxes or delivers the result to a clinic, gets an order for oxygen and sets up oxygen on the patient. This process takes two to three days.

The funny thing is that Medicare actually approves of this system.

There are ways to manipulate pulse ox readings as well. We therapists have found that fingernail polish can show false readings. Poor perfusion in the extremities and hypothermia can also result in false readings.

Poor instructions to the patient on the proper placement of the finger probe can cause an inadequate reading. For these reasons, I feel it necessary that a medical professional who is aware of these potential hazards which may indicate false readings should perform the oximetry test on patients.

Bonus payments can be motivations to entice workers to try to get oxygen orders within a given time frame. Certificates of Medical Necessity (CMNs) can play a part here. Medicare accepts stamped signatures, faxed CMNs and electronically completed CMNs. Faxed forms are especially prone to tampering because with a copier, white out and a shredder, a caregiver can do just about anything and no one will ever know.

Changes Might Help

You can fight back. Listed below are ten changes that could protect Medicare from fraud and abuse:

1. All patients on home oxygen should be required to be re-tested every six months in order to continue billing.

2. Independent testing sites should perform all qualifying oxygen saturation tests, with policies and procedures followed for each test done at rest on room air, exercise on room air and/or nocturnal on room air, at rest on oxygen, exercise on oxygen and/or nocturnal on oxygen. This testing site should work directly with Medicare. Logically these testing sites could be located within local health department units.

3. Each testing site should calibrate and inventory by serial number each oximetry unit daily and maintain a log of each unit for auditing purposes.

4. A detailed patient assessment which contains the patient’s diagnosis, physical and cardiopulmonary limitations, blood pressure and pulse and respiratory rates should be kept on file at the test site.

5. On completion of oximetry testing, the results should be mailed or faxed to Medicare and to the patient’s physician. The original test results should be kept on file at the testing site. At no time should testing-site staff communicate with DME suppliers or in-home patient care agencies.

6. It should be the physician’s responsibility to provide suppliers with a copy of the test results and complete the qualifying test result section on the CMN.

Patients on continuous positive airway pressure (CPAP) or bilevel who have oxygen in-line due to saturations below 88 percent during a sleep study should be re-tested every six months on oxygen and on room air.

8. Nocturnal oximetry should be monitored and saturations documented every 5 to 15 minutes as deemed necessary. Documentation should include date, time on or off oxygen, CPAP pressure, respiratory rate and pulse.

9. Documented oxygen concentrator service and monitoring should be required and accompany the test results. All concentrators should be analyzed for the correct output percentage of oxygen.

10. A compliance policy should be implemented to ensure all patients with oxygen, CPAP, BiPAP and nebulizer therapy who receive medications through their DME supplier are compliant and using their equipment as ordered by their physician.

Cooperation Needed

It will take Medicare administrators, government agencies and physicians working together to come up with an improved plan that will benefit all patients and cut costs considerably within two years. Only about 70 percent of the patients currently getting home oxygen really need it. That other 30 percent are still being billed at a high cost. Consider:

  • The average monthly billing for a concentrator or liquid base is $160.
  • The Average monthly billing for portable oxygen is $64.
  • The average number of patients per DME supplier is 200.
  • Of these, 30 percent (some 66 patients) do not require oxygen.
  • The savings for two years in not providing oxygen to these 66 patients who don’t need it is $25,588.

    Significant Savings

    These figures are a representative sample taken from just one DME supplier. You do the math on a national scale, and you will find there could be a significant total savings.

    For more information on Medicare and Medicaid fraud and abuse, visit the following Web sites:

    Centers for Medicare and Medicaid Services at http://www.cms.hhs-gov.

    Office of Inspector General (OIG) Fraud Hotline at (800) HHS-TIPS or visit

    Trust Solutions LLC at

    As a caregiver, it is important for you to stay in compliance by doing the right thing in providing patient care! You can help save the Medicare and Medicaid programs that might save you down the line.

    Teresa Tetrick is a traveling therapist and freelance writer.

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