The FBI & DOJ targeted alleged schemes involving the payment of illegal kickbacks and bribes by DME companies in exchange for the referral of Medicare beneficiaries by medical professionals working with fraudulent telemedicine companies for back, shoulder, wrist and knee braces that were medically unnecessary. Some of the defendants allegedly controlled an international telemarketing network that lured over hundreds of thousands of elderly and/or disabled patients into a criminal scheme that crossed borders, involving call centers in the Philippines and throughout Latin America.
“Another data point shows just how greatly Medicare’s importance as a revenue driver for HME has dropped. In addition to Medicare’s 16 percent share, Medicaid accounted for 15 percent of HME spending, and all other sources, such as private payer and retail sales, represented 68 percent of HME spending.”
“In Los Angeles, eight defendants were charged for their roles in schemes to defraud Medicare of approximately $66 million. In one case, a doctor is charged with causing almost $23 million in losses to Medicare through his own fraudulent billing and referrals for DME, including over 1000 expensive power wheelchairs and home health services that were not medically necessary and often not provided.”
“In a shift from the current system, Medicare is proposing to rule on seniors’ coverage for home medical devices before the supplies are delivered or claims for payment are submitted. The Centers for Medicare and Medicaid Services CMS is planning to expand the use of “prior authorization” for power scooters and wheelchairs, and introduce the process for several other categories of medical goods used at home.
Officials said the effort is targeting improper payments and fraud in the system, when Medicare foots the bill for products aggressively marketed to patients and doctors who do not need them.”