DME Upcoding: Legal Cases

Talk to an Atlanta DME Fraud Lawyer at (404) 550-4615

In a 2012 investigation, the Center for Public Integrity reported that Medicare has lost a staggering $11 billion to upcoding of medical services and equipment. When a DME provider “upcodes,” that means that it charges the Government for an expensive piece of medical equipment, when in fact it provided a much cheaper product or service to the patient. Under the False Claims Act (FCA), whistleblowers (also known as “relators”) who file a successful qui tam suit under the False Claims Act are entitled to between 15% and 30% of the money they helped the Government recover from the DME company that was upcoding.

Call our Atlanta DME fraud attorney today to discuss the fraud you’ve witnessed.

Doctors & Hospitals Have Collected Billions in Questionable Medicare Fees

Medicare has lost $11 billion to fraud by hospitals, physician practices and labs that have upcoded the medical services and equipment they provide to patients. When a healthcare company upcodes the durable medical equipment that it provides to patients, it sends in paperwork saying that it provided the beneficiary with a certain piece of equipment, when in reality the DME provider gave the patient a cheaper type of equipment. Taxpayers, of course, are the losers, because they pay for equipment that was never provided to a patient.

Examples of DME fraud could include or have included all of these scenarios:

  • One DME provider billed Medicare for full-torso, thoracic lumbar sacral orthotic braces, but beneficiaries got nothing more than a small, flexible neoprene brace;
  • Durable Medical Equipment providers provide patients with manual wheelchairs, but bill Medicare and Medicaid for ultra-expensive electric wheelchairs.
  • DME providers give beneficiaries one month’s worth of supplies, but charge Medicare and Medicaid for a 3-month supply.

Of course, these examples are just a sampling of the upcoding that a DME provider might do; DME providers of course can and have thought of countless other schemes for upcoding so that they can overbill Medicare, Medicaid, CHAMPUS and other federally-funded healthcare programs.

“Check the Right Boxes” Fraud

The Centers for Medicare and Medicaid Services, or CMS, is growing increasingly concerned about upcoding fraud. As healthcare providers move to computerized systems, it becomes easier for them to — literally – “check all the right boxes.” DME companies, of course, can check boxes that suggest that their beneficiaries received an expensive type of product, when in fact they actually received a much cheaper product.

(Before a DME provider can provide equipment or medical supplies to a beneficiary, it has to have in hand a physician’s order that states that the patient has an actual, medical need for the equipment or supplies. DME companies cannot charge the federal healthcare programs unless the beneficiary has a “medical necessity” for the product or supplies.

Recently, a number of cases have addressed situations where durable medical equipment providers have colluded with doctors to get physician orders for equipment and supplies that the beneficiaries did not really need. This sort of fraud is also made much easier by the advent of “check the box” computer systems in doctors’ offices. Technically speaking, this fraud is not true “upcoding,” at least not when the beneficiary actually receives the product for which Medicare or Medicaid was billed, but of course it is still illegal and can justify a False Claims Act lawsuit.)

You Can Recover Money by Reporting Fraud: (404) 550-4615

If you have information about a DME that is upcoding, you can help the Government stem the tide of Medicare money flowing out to fraudsters. By filing suit under the False Claims Act as a whistleblower/relator, you can help U.S. taxpayers and collect between 15% and 30% of the money that the Government gets back as a result of the information you gave them.

Lee Wallace of The Wallace Law Firm, LLC graduated first in her class at Vanderbilt University and with honors from Harvard Law School. She devotes her practice to representing brave whistleblowers like you.

Reach our office at (404) 550-4615 to see what you can do to help the government.