Durable Medical Equipment Fraud

Durable Medical Equipment (“DME”) fraud is on the rise as our population continues to age. Wheelchairs, prosthetic devices, portable oxygen tanks, orthotics, implants and related services — DME fraud hinders society’s ability to provide appropriate healthcare to our elderly and disabled.

DME fraud often involves issues such as:

  • payments to reward the referral of patients
  • various types of billing-related fraud, including:
    • upcoding, which occurs when a health care provider submits a claim for an item of durable medical equipment which misuses standardized billing codes so as to obtain more money than is allowed by law;
    • submission of a claim for durable medical equipment that were never delivered to a valid patient; and
    • lack of medical necessity, a fraud where a health care provider submits a claim for durable medical equipment that are not medically necessary.

Durable medical equipment fraud resulting in whistleblower rewards include:

Gambro Healthcare Agrees to Pay More Than $500 Million in Medicare Fraud Case

The relator in the case received more than $45 million for helping the government to uncover allegations that Gambro Healthcare:

  • provided home dialysis patients equipment and supplies through a “shell” durable medical equipment company solely to receive higher reimbursement;
  • hired and compensated physicians as medical directors based on the number and volume of anticipated patient referrals to Gambro clinics; and
  • engaged in “hard coding” of diagnostic codes on submitted claims, resulting in bills being submitted for ancillary medications and services which were not medically necessary.