Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
ORDERING MEDICARE EQUIPMENT 
AND SUPPLIES 
Physicians Perspectives 
JUNE GIBBS BROWN 
Inspector General 
FEBRUARY  1999 
OEI-02-97-00081  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's New York Regional Office prepared this report under the direction of John I. Molnar, 
Regional Inspector General and Renee C. Dunn, Deputy Regional Inspector General.  Principal 
OEI staff included: 
REGION  HEADQUARTERS 
Lucille Cop, RN  Brian Ritchie 
Steve Shaw  Barbara Tedesco 
Ellen Vinkey  Winnie Walker 
Stuart Wright 
Carmen Sanchez, Administration on Aging 
To obtain copies of this report, please call the New York Regional Office at (212) 264-2000. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  E X E C U T I V E   S U M M A R Y  
PURPOSE 
To report perceptions of physicians about the process of ordering medical equipment and 
supplies for their Medicare patients. 
BACKGROUND 
In general, Medicare recognizes the physician as the key figure in determining the 
appropriate utilization of all medical services.  Accordingly, Medicare requires that 
payment for certain non-physician services, such as medical equipment and supplies, are 
conditional on the existence of a physician's order or certificate of medical necessity which 
must be kept on file by the supplier. 
We are undertaking a series of studies to look at the role of the physician in certifying 
these non-physician services.  This first report is about physicians perceptions of the 
certification process for durable medical equipment, prosthetics, orthotics, and supplies 
(DMEPOS).  A subsequent report will look at whether the relationship between the 
physician and the patient affects the certification of the medical equipment and supplies 
provided.  We based this report on the analysis of questionnaires sent to physicians who 
certified a sample of 1000 medical equipment or supply items. 
FINDINGS 
Two-thirds of Physicians Are Satisfied With the Current Process of Ordering 
Medical Equipment and Supplies; One-fifth Are Not 
When asked to describe their level of satisfaction with the current Medicare process of 
ordering medical equipment and supplies, two-thirds of physicians (68 percent) say they 
are either satisfied or very satisfied with the current process.  Approximately one-fifth (22 
percent) of physicians are either dissatisfied or very dissatisfied with Medicares ordering 
procedure.  Regardless of satisfaction, many physicians suggested changes such as making 
the ordering process easier and less time consuming. 
1 
Ordering Medicare Equipment  OEI-02-97-00081  Information About Medicare Requirements Plays a Significant Role in Physician 
Satisfaction Rates 
Seventy-nine percent of physicians who report receiving sufficient information about the 
requirements for ordering medical equipment or supplies are satisfied.  Of physicians who 
report not receiving enough information, only 46 percent are satisfied.  Almost one-
quarter of physicians surveyed requested additional information about the ordering 
process.  The most commonly requested information includes more detailed rules and 
specific criteria regarding Medicare coverage and eligibility.  Seventy-five percent of 
physicians reported they have never received any educational materials from their 
Medicare carrier concerning the equipment and supply ordering process. 
Medical Specialty Also Plays a Role 
Pulmonary disease specialists express the most dissatisfaction with the process.  Almost 
one-half (43 percent) of them are dissatisfied as compared to the overall dissatisfaction 
rate of 22 percent. 
Half of Physicians View the Certificate of Medical Necessity as Effective; One-fifth 
Do Not 
While 56 percent of physicians say the certificate of medical necessity is effective, 21 
percent say it is not effective and another 23 percent dont know.  Physicians view the 
certificate of medical necessity as an effective monitor of fraud and abuse and quality of 
care.  Sixty-seven percent of physicians report that on the average, it takes less than 15 
minutes to complete and sign a certificate.  Another 31 percent report that this procedure 
takes somewhere between 15 and 30 minutes. 
Some Physicians Have Sometimes Refused to Sign Certificates of Medical 
Necessity 
Fifty-two percent of physicians say they have at some time refused a request to sign a 
certificate of medical necessity; however, two-thirds of these physicians say this rarely 
happens.  Of the physicians who have refused to sign a certificate, the supplier has initiated 
the request approximately one-half of the time.  The predominant reason physicians 
refused to sign these requests is because the patient did not need the equipment or supplies 
listed on the certificate.  Additionally, physicians say their refusal is often because they did 
not know the patient. 
2 
Ordering Medicare Equipment  OEI-02-97-00081  Some Have Encountered Problems When Ordering Medical Equipment and 
Supplies 
Twenty-one percent of physicians encounter problems when they order medical equipment 
and supplies for their patients.  Among these physicians, the problems include 
inappropriate equipment and supplies, upgrading and downgrading of equipment and 
supplies, and patients getting the wrong equipment and supplies.  Further, physicians also 
see unclear rules for ordering medical equipment and supplies as a problem. 
RECOMMENDATION 
We recommend that the Health Care Financing Administration strengthen its efforts to 
educate physicians regarding their ordering of medical equipment and supplies.  The 
following approaches are suggested: 
<	 directing the carriers to furnish all physician providers with information about 
ordering medical equipment and supplies including any OIG Fraud Alerts.  Of 
particular interest is the OIG Fraud Alert on Physician Liability for Certifications in 
the Provision of Medical Equipment and Supplies and Home Health Services 
which specifically highlights physicians responsibilities in making certifications for 
durable medical equipment and supplies, and the legal significance of the 
certifications.  A copy of this fraud alert may be found in Appendix D; 
<	 routinely providing all physicians with any changes of coverage and payment rules 
for medical equipment and supplies; 
<	 providing all physicians with a contact person at the carriers to answer questions 
about equipment or supplies; and 
<	 assuring that all certificates of medical necessity sent from the suppliers to 
physicians include the coverage and payment rules and cost of the equipment for 
the specific equipment or supplies ordered. 
COMMENTS 
We received comments on the draft report from HCFA.  They generally concur with our 
recommendation.  Based on their comments we changed one of the suggested approaches 
in our recommendation on providing physicians with information about ordering medical 
equipment and supplies by expanding it to apply to all physicians not just new ones.  The 
HCFAs comments are reproduced in Appendix E. 
3 
Ordering Medicare Equipment  OEI-02-97-00081  We also received comments from the Assistant Secretary for Planning and Evaluation 
(ASPE).  We changed the wording of another of our suggested approaches in the 
recommendation to clarify that the information about coverage and payment rules had to 
do with the specific equipment and supplies ordered rather than general guidelines. 
4 
Ordering Medicare Equipment  OEI-02-97-00081  T A B L E   O F   C O N T E N T S 
PAGE

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

FINDINGS

Overall Satisfaction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Need for Information about Medicare Requirements  . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Specialty Plays a Role  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Effectiveness of Certificates of Medical Necessity  . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Physicians Refuse to Sign Certificates  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14

Problems Encountered in Ordering Supplies and Equipment . . . . . . . . . . . . . . . . . . . . .  14

RECOMMENDATION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  16

APPENDICES

A: Confidence Intervals for Key Survey Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

B: Non-respondent Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

C: Statistical Tests for Key Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

D: Fraud Alert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

E: Comments on the Draft Report  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

5 
Ordering Medicare Equipment  OEI-02-97-00081  I N T R O D U C T I O N 
PURPOSE 
To report perceptions of physicians about the process of ordering medical equipment and 
supplies for their Medicare patients. 
BACKGROUND 
In general, Medicare recognizes the physician as the key figure in determining the 
appropriate utilization of all medical services.  Accordingly, Medicare requires that 
payment for certain non-physician services, such as home health agency, therapy and 
diagnostic services, as well as medical equipment and supplies, are conditional on the 
existence of a physician's order.  According to Medicare regulation 42 CFR Section 424, 
the provider of these services is generally responsible for obtaining the physician 
certification and re-certification statements, and for keeping them on file for verification. 
We are undertaking a series of studies to look at the role of the physician in certifying 
these non-physician services.  This first report is about physicians perceptions of the 
certification process for durable medical equipment, prosthetics, orthotics, and supplies 
(DMEPOS). This includes: wheelchairs and hospital beds; prosthetics and orthotics; 
catheters, ostomy, incontinence, enteral and parenteral nutrition, and wound care supplies. 
For the purposes of this report, we will refer to DMEPOS as medical equipment and 
supplies.  A subsequent  report will look at whether the relationship between the physician 
and the patient effects the certification of the medical equipment and supplies provided. 
Medicare Expenditures for Medical Equipment and Supplies 
According to published Health Care Financing Administration statistics (HCFA), in 1995, 
Medicare paid an estimated $4.7 billion for medical equipment and supplies under part A 
and part B of the program.  Part A, hospital insurance, covers services which are furnished 
by hospitals in an inpatient setting, home health agencies, and skilled nursing facilities. 
Part B, supplementary medical insurance, covers a wide array of non-institutionalized 
care.  These include physician services, medical equipment and supplies, outpatient 
hospital services, diagnostic laboratory tests, x-rays, and ambulance services. 
6 
Ordering Medicare Equipment  OEI-02-97-00081  The HCFA administers Medicare and contracts with private insurance companies to 
process and pay claims.  Contractors that process claims for Part A, such as those for 
home health agency services, are considered fiscal intermediaries.  Contractors that 
process claims for Part B, such as those for medical equipment and supplies, are 
considered carriers. 
Medicare Durable Medical Equipment Regional Carriers 
In October 1993, HCFA began processing claims for medical equipment and supplies 
through four Durable Medical Equipment Regional Carriers (DMERCs).  These four 
carriers are responsible for all 50 States, the District of Columbia, and Puerto Rico.  These 
entities are responsible for ensuring that coverage requirements are met before approving 
payment.  Although fiscal intermediaries also process some claims for medical equipment 
and supplies through the Part A coverage of home health agency services, this report will 
focus only on medical equipment and supplies that are covered by Part B and are 
processed by the DMERCs. 
Certification of Medical Equipment and Supplies 
Medicare pays for medical equipment and supplies that are ordered or prescribed by a 
treating physician and are appropriate for the patients diagnosis and symptoms as 
determined by the DMERCs.  Suppliers must obtain and keep on file a physician's order or 
prescription for all the medical equipment and supplies they bill to Medicare. 
In addition to HCFA's requirement that suppliers have a physician's order or prescription 
on file, HCFA requires that certain medical equipment and supplies have a document 
called a certificate of medical necessity (CMN).  It states that the service or item claimed 
for reimbursement is medically necessary and reasonable.  For the reimbursement of these 
items, a completed CMN must be submitted to the DMERCs. 
The items within the following 14 medical equipment and supply groups require a CMN: 
hospital beds
  motorized wheelchairs 
  
 support surfaces 
  manual wheelchairs 
 
lymphedema pumps
 osteogenesis stimulators 
   
 Transcutaneous Electrical
 Continuous Positive Airway 
  
Nerve Stimulators (TENS) 
 Pressure (CPAP) devices 
 seat lift mechanisms
  power operated vehicles 
 
 parenteral nutrition
  enteral nutrition 
 
 home oxygen therapy
  infusion pumps 
 
7 
Ordering Medicare Equipment  OEI-02-97-00081  The CMNs requirements were revised in October of 1995.  They were standardized and 
reformatted by HCFA and the DMERCs.  Each of the aforementioned medical equipment 
and supply groups now have separate CMNs. 
CMNs now have four sections: A, B, C, and D.  Section A is to be filled out by suppliers. 
Section B lists the clinical justifications or the medical necessity of the device.  This 
section is not to be filled out by the supplier, but may be completed and signed by a non-
physician clinician, or a physicians employee.  Section C contains information regarding 
the cost of the device and is to be filled out by the supplier.  Section D must be signed by 
the physician certifying the medical necessity of the device and that the information in 
Section B is correct.  With certain exceptions, this certifying physician cannot have any 
financial or contractual relationship with the supplier of the item.  As of 1997, the 
physician signing section D must also be the patients treating physician. 
Office of Inspector General Activities 
There have been many OIG efforts related to the utilization of non-physician services, 
including  the role of physician authorization in the provision of these services.  An OIG 
study entitled "The Physician's Role in Home Health Care" (OEI-02-94-00170) found that 
at least 91 percent of the physicians who certified the plan of home health care had a pre-
existing relationship with the patient for whom the plan was designed. 
Other related OIG work includes an audit of Medicare home health agency services in 
California, Illinois, New York and Texas (A-04-94-02121) to determine whether 
payments for these fulfilled Medicare reimbursement requirements.  The results of this 
audit showed that physicians did not always review or actively participate in developing 
plans of care they signed.  The auditors said that physicians relied heavily on home health 
agencies to make homebound determinations and develop the plans of care for home 
health services. 
METHODOLOGY 
Using a 1 percent sample of HCFAs 1996 National Claims History (NCH) data, we 
selected a stratified, random sample of 1000 medical equipment and supply items.  We 
stratified our sample between codes that require a CMN and codes that do not.  We then 
further stratified the CMN codes between oxygen and non-oxygen items.  This ensured 
that oxygen related line items were not over-represented in our sample. 
Within the non-CMN stratum, we selected medical equipment and supply line items from 
HCPCS codes where each item cost was more than $103 or where HCFA allowed more 
than $260,000 in 1996.  These codes accounted for 96 percent of all the medical 
equipment and supply line items in 1996 and 99 percent of the total monetary amount 
8 
Ordering Medicare Equipment  OEI-02-97-00081  allowed by HCFA in 1996.  We further divided the 724 non-CMN codes into three 
separate groups:  one containing five codes which account for 30 percent of all non-CMN 
line items; another with 20 codes which account for an additional 30 percent; and, finally, 
one with the remaining non-CMN codes.  This prevented any over-representation in our 
non-CMN stratum.  We randomly selected 200 line items from each of the 5 stratum for a 
total of 1000 items. 
Physician Survey 
We mailed a questionnaire to the physicians certifying equipment for the 1000 line items in 
our sample in November 1997 to gain their perceptions of the certification process. 
Physicians responded to questions about their level of satisfaction with the process for 
ordering medical equipment and supplies, their experiences with CMNs, and whether or 
not they would suggest any changes to the current process.  Response estimates and 
confidence intervals for key questions in our survey are listed in Appendix A. 
We conducted a second and third mailing to non-respondents and 695 questionnaires were 
returned to us, for an overall response rate of 69 percent.  Our response rates between 
strata were almost identical: 70 percent for non-CMN items (strata 1, 2, and 3) and 68 
percent for CMN items (strata 4 and 5).  We then weighted the data collected from these 
695 questionnaires by stratum. 
Of the 305 physicians who did not complete the questionnaire, 243 physicians did not 
respond at all.  Of the remaining 62 physician non-respondents, 38 physicians could not be 
located and 24 physicians were retired and refused to fill out the survey.  We conducted a 
non-respondent analysis of all physicians in our sample by analyzing several variables that 
may have influenced responses.  See Appendix B for this analysis. 
This inspection was conducted in accordance with the Quality Standards for 
Inspections  issued by the Presidents Council on Integrity and Efficiency. 
9 
Ordering Medicare Equipment  OEI-02-97-00081  F I N D I N G S
Two-thirds of physicians are satisfied with the current
process of ordering medical equipment and supplies; One-
fifth are dissatisfied
Sixty-eight percent of physicians are satisfied; twenty-two percent are
dissatisfied
When asked to describe their level of satisfaction with the current Medicare process of
ordering medical equipment and supplies, two-thirds of physicians (68 percent) say they
are either satisfied or very satisfied with the current process (See Figure A below). 
Approximately one-fifth (22 percent) of physicians are either dissatisfied or very
dissatisfied with Medicares ordering procedure.  The remaining 11 percent expressed no
opinion.
                                                                                                                                                                                                                                      
10
Ordering Medicare Equipment                                                                                                                                                   OEI-02-97-00081 According to physicians, the process of ordering medical equipment and supplies generally 
occurs in several different ways.  Most often the physician gives a prescription to the 
patient who takes it to the supplier.  When the patient is in the hospital, the physician 
usually contacts the hospital discharge planner or social worker who orders the equipment 
or supplies.  When the patient is receiving home health care, the physician may discuss the 
equipment or supplies with the home health agency person who actually places the order. 
Most physicians indicate that they, along with the patient or patients family, make the 
decision about what equipment or supplies the patient needs and which supplier to get it 
from. 
Most physicians (61 percent) also report that they find out whether the patient received 
the equipment or supplies through some sort of follow-up with the patient.  More than half 
(54 percent) of the physicians describe the needed item in detail, while just over one-
quarter (27 percent) say that the supplier makes the decision about the particular brand of 
item to be furnished. 
Regardless of satisfaction, many physicians suggest changes to the current Medicare 
process for ordering medical equipment and supplies.  Of the 22 percent of physicians who 
are dissatisfied, almost all suggest improvements to the present ordering system. 
Physicians report that they would like a simpler and less time consuming durable medical 
equipment ordering process.  For example, one physician responded, it is extremely 
difficult to give each request careful attention.  However, physicians also report concerns 
that there are not always enough safeguards in the process.  One physician summed these 
contrasting opinions with his statement, Its never easy for either side when it comes to 
paperwork, but the paper trail is necessary to prevent abuses. 
Physicians satisfaction levels do not differ significantly based upon the DMERCs that 
process their claims for medical equipment and supplies.  Further, satisfaction levels are 
similar among the four US geographic regions that are designated by the Census Bureau: 
Northeast, Midwest, South, and West.  Finally, physicians who order equipment that 
requires a certificate of medical necessity (CMN ) have identical satisfaction rates (79 
percent) as physicians who do not.  See Appendix C for this analysis. 
Information about Medicare requirements plays a significant 
role in physician satisfaction rates 
Physicians that receive sufficient Information are more likely to be satisfied 
Seventy-nine percent of physicians who report receiving sufficient information about the 
requirements for ordering medical equipment or supplies are satisfied.  Of physicians who 
report not receiving enough information, only 46 percent are satisfied. 
11 
Ordering Medicare Equipment  OEI-02-97-00081  Almost one-quarter of physicians requested additional information about the ordering 
process.  The most commonly requested information includes more detailed rules and 
specific criteria regarding Medicare coverage and eligibility.  Some physicians suggest that 
doctors who are new providers should get a packet of information on the Medicare 
process for ordering durable medical equipment.  One respondent requested that a manual 
be distributed to all physicians about the certification of Medicare covered durable medical 
equipment. 
Physicians also report the need for additional information regarding the criteria for 
ordering equipment and supplies.  In fact, 75 percent of physicians reported they have 
never received any educational materials from their Medicare carrier concerning the 
equipment and supply ordering process.  One physician echoed the sentiments of many 
with his comment, I am unclear as to the standards to be applied and documentation 
required.  I would like more education..... 
Medical specialty also plays a role 
Pulmonary disease specialists are the most dissatisfied 
Pulmonary disease specialists express the most dissatisfaction with the process.  Almost 
one-half (43 percent) are either dissatisfied or very dissatisfied, as illustrated in Table A 
below.  Reasons cited for physicians dissatisfaction include too much paperwork, 
complex forms, and time constraints.  One pulmonologist expressed these thoughts, I am 
being asked to re-document the need for equipment to treat chronic illnesses which never 
go away.  Please stop making us do this over and over again. 
General surgeons and ophthalmologists are the most satisfied among all specialties.  Only 
5 percent of general surgeons and 6 percent of ophthalmologists expressed some degree of 
dissatisfaction.  The dissatisfaction rate of the remaining physician specialties ranges 
between 17 percent and 29 percent.  This is close to the overall physician dissatisfaction 
mean of 22 percent. 
12 
Ordering Medicare Equipment  OEI-02-97-00081  Table A 
Physician Dissatisfaction By Specialty 
Specialty  Percent Dissatisfied 
Pulmonary Disease  43% 
Physical Medicine and Rehabilitation  29% 
Family Practice  28% 
Cardiology  25% 
Internal Medicine  22% 
Overall Specialty Average  22% 
General Practice  22% 
Other  19% 
Orthopedic Surgery  18% 
Ophthalmology  6% 
General Surgery  5% 
Half of physicians view the certificate of medical necessity 
as effective 
While 56 percent of physicians say the CMN is effective, 21 percent say the CMN 
is not effective and another 23 percent dont know 
Physicians in support of the CMN say it allows them to review the condition of their 
patients.  The form reminds physicians to periodically check their patients status and 
analyze current and future equipment needs.  Further, physicians point to the CMN as an 
effective monitor of fraud and abuse.  One physician stated, I believe that the vast 
majority of times the CMN assures the proper use of medical equipment. 
Physicians who report the CMN as not being effective question whether or not the form 
assures improved utilization.  These physicians also suggest that CMNs present additional 
unnecessary paperwork burdens and are often cumbersome. 
13 
Ordering Medicare Equipment  OEI-02-97-00081  However, 67 percent of physicians report that on the average, it takes less than 15 minutes 
to complete and sign a CMN.  Additionally, another 31 percent report that this procedure 
takes somewhere between 15 and 30 minutes.  Only 2 percent of physicians report 
spending more than thirty minutes to complete and sign a CMN. 
Physicians report the supplier sometimes fills out Section B 
Section B of the CMN lists the clinical justifications or the medical necessity of the device. 
This section is not to be filled out by the supplier.  This section may be completed by a 
non-physician clinician or a physicians employee as well as the physician.  When the 
physician signs the CMN, he agrees to the accuracy of the information provided in Part B. 
When asked who usually fills out Section B of the CMN, physicians usually gave more 
than one answer.  One-fourth of physicians (24 percent) responded that the supplier 
sometimes fills it out.  Additionally, 78 percent reported that the physician sometimes 
completes this section.  Other responses include therapists or home health agency staff. 
Some physicians have sometimes refused to sign 
certificates of medical necessity 
Half of physicians have refused to sign a CMN at least once 
While 52 percent of physicians say they have at some time refused to sign a CMN request, 
two-thirds of these physicians say this rarely happens.  Of the physicians who have refused 
to sign a CMN, the supplier has initiated the request approximately one-half of the time. 
The predominant reason physicians refused to sign these requests is because the patient 
did not need the equipment or supplies listed on the CMN.  Additionally, physicians say 
their refusal is often because they did not know the patient. 
Some have also encountered problems when ordering 
medical equipment and supplies 
One in five physicians have encountered problems when ordering equipment 
and supplies 
Twenty-one percent of physicians encounter problems when they order medical equipment 
and supplies for their patients.  Of these physicians, problems include inappropriate 
equipment and supplies, upgrading and downgrading of equipment and supplies, and 
14 
Ordering Medicare Equipment  OEI-02-97-00081  providing the wrong equipment and supplies.  Physicians believe that inappropriate 
equipment and supplies and the wrong equipment and supplies are the greatest problems. 
Further, physicians request clearer ordering rules and detailed descriptions of equipment 
and supplies they order.  One physician stated, I would appreciate any updated equipment 
need criteria to ensure who qualifies for what equipment and what specific criteria must be 
met during the ordering process. 
15 
Ordering Medicare Equipment  OEI-02-97-00081  R E C O M M E N D A T I O N  
We recommend that the Health Care Financing Administration strengthen its efforts to 
educate physicians regarding their ordering of medical equipment and supplies.  The 
following approaches are suggested: 
<	 directing the carriers to furnish all physician providers with information about 
ordering medical equipment and supplies including any OIG Fraud Alerts.  Of 
particular interest is the OIG Fraud Alert on Physician Liability for Certifications in 
the Provision of Medical Equipment and Supplies and Home Health Services 
which specifically highlights physicians responsibilities in making certifications for 
durable medical equipment and supplies, and the legal significance of the 
certifications.  A copy of this fraud alert may be found in Appendix D; 
<	 routinely providing all physicians with any changes of coverage and payment rules 
for medical equipment and supplies; 
<	 providing all physicians with a contact person at the carriers to answer questions 
about equipment or supplies; and 
<	 assuring that all certificates of medical necessity sent from the suppliers to 
physicians include the coverage and payment rules and cost of the equipment or 
supplies for the specific equipment or supplies ordered. 
COMMENTS 
We received comments on the draft report from HCFA.  They generally concur with our 
recommendation.  Based on their comments we changed one of the suggested approaches 
in our recommendation on providing physicians with information about ordering medical 
equipment and supplies by expanding it to apply to all physicians not just new ones.  The 
HCFAs comments are reproduced in Appendix E. 
We also received comments from the Assistant Secretary for Planning and Evaluation 
(ASPE).  We changed the wording of another of our suggested approaches in the 
recommendation to clarify that the information about coverage and payment rules had to 
do with the specific equipment and supplies ordered rather than general guidelines. 
16 
Ordering Medicare Equipment  OEI-02-97-00081  APPENDIX A 
Confidence Intervals For Key Survey Questions

We calculated confidence intervals for 14 key questions from the physician questionnaire. 
The response estimate and 95 percent interval are given for each of the following: 
1. 	 How would you describe your level of satisfaction with current Medicare process 
for ordering medical equipment and supplies? 
Very or somewhat satisfied response estimate: 68% 
Lower interval: 66% 
Upper interval: 70% 
2.	 Would you make any changes to the process of ordering medical equipment 
and supplies? 
Yes response estimate: 54% 
Lower interval: 51% 
Upper interval: 57% 
3.	 Have you ever received any educational materials from your Medicare carrier 
regarding the provision of medical equipment or supplies? 
No response estimate: 75% 
Lower interval: 73% 
Upper interval: 77% 
4.	 Do you feel that you have been provided sufficient information with regard to the 
criteria for ordering medical equipment and supplies for Medicare beneficiaries? 
No response rate: 23% 
Lower interval: 21% 
Upper interval: 26% 
5.	 Who primarily decided the patient needed the equipment or supplies? 
I did and the patient or the patients family response estimate: 82% 
Lower interval: 80% 
Upper interval: 84% 
17 
Ordering Medicare Equipment  OEI-02-97-00081  6.	 Who primarily selected the company that provided the equipment or supplies? 
I did and the patient or the patients family response estimate: 55% 
Lower interval: 52% 
Upper interval: 57% 
7.	 Generally, how does the process of ordering medical equipment and supplies 
work for you? 
I give a prescription to a patient who takes it directly to the supplier 
response rate: 62% 
Lower interval: 60% 
Upper interval: 65% 
8.	 When you order equipment or supplies, who generally describes the type of item in 
detail? 
I do response rate: 54% 
Lower interval: 51% 
Upper interval: 56% 
9.	 How do you know if your patients receive the equipment or supplies? 
I follow up/I call or see the patients response rate: 61% 
Lower interval: 58% 
Upper interval: 63% 
10.	 Have you ever encountered any problems when ordering equipment or supplies 
for your patients? 
Yes response rate: 21% 
Lower interval: 19% 
Upper interval: 22% 
11.	 In your opinion, is the use of the CMN effective to assure the proper utilization of 
medical equipment and supplies? 
Yes response rate: 56% 
Lower interval: 53% 
Upper interval: 58% 
18 
Ordering Medicare Equipment  OEI-02-97-00081  12.	 Have you ever received a request to sign a CMN that you refused to sign? 
Yes response rate: 52% 
Lower interval: 50% 
Upper interval: 55% 
13.	 What are some of the reasons that you did not sign these requests? 
The patient did not need the equipment or supplies response rate: 70% 
Lower interval: 67% 
Upper interval: 73% 
14.	 Who is most likely to initiate a request that you do not sign? 
The supplier response rate: 44% 
Lower interval: 41% 
Upper interval: 47% 
15.	 On the average, how long does it take you to complete and sign a CMN? 
Less than 15 minutes response rate: 67% 
Lower interval: 64% 
Upper interval: 70% 
19 
Ordering Medicare Equipment  OEI-02-97-00081  APPENDIX B 
Non-respondent Analysis

When questionnaires are used to collect data, the results may be biased if non-respondents 
differ from respondents.  For this inspection, a physician for whom a questionnaire was 
not received is a non-respondent.  A total of 695 questionnaires were completed, for an 
overall response rate of 69 percent.  The remaining 305 questionnaires were not 
completed, for a non-respondent rate of 31 percent.  Table B illustrates the number of 
responses and the response rate by strata without weights: 
Table B 
Physician Response Rate By Strata 
Strata  Number  Response Rate 
1  144  72% 
2  152  76% 
3  126  63% 
4  147  73% 
5  126  63% 
Total Respondents  695  69% 
To test for the presence of any non-response bias, we analyzed the variables that might 
influence whether or not a physician would respond to the questionnaire.  For the 
physicians in our sample, we examined geographic region, Durable Medical Equipment 
Regional Carriers, and physician specialty.  These categorical variables were weighted and 
tested using Chi-square with the appropriate degrees of freedom.  The results for this 
analysis are presented in tables B-1, B-2, and B-3.  The Chi-square values given in the 
tables provide a test of the difference between the distribution of the respondents and that 
of the non-respondents for the variable of interest.  Also provided in the tables are the 
response rate by the different values of the variables. 
20 
Ordering Medicare Equipment  OEI-02-97-00081  Table B-1 
Geographic Region 
Respondents  Non-Respondents  Total  Response 
Rate 
Northeast  62603.61  20%  22827.42  16%  85431.03  73% 
Midwest  75503.61  24%  35977.64  26%  111481.25  68% 
South  128250.45  40%  61614.44  44%  189864.89  68% 
West  50456.71  16%  19126.42  14%  69583.13  73% 
Total  316814.38  100%  139545.92  100%  456360.30  69% 
CHI-SQUARE = 2.38 
Degrees of Freedom = 3 
Table B-2 
Durable Medical Equipment Regional Carriers 
Respondents  Non-Respondents  Total  Response 
Rate 
Region A  62588.04  19%  23992.45  15%  86580.49  72% 
Region B  73518.87  22%  38621.84  24%  112140.71  66% 
Region C  131585.18  40%  73349.88  46%  204935.06  64% 
Region D  61067.50  19%  22692.24  15%  83759.74  73% 
Total  328759.59  100%  158656.41  100%  487416.00  68% 
CHI-SQUARE = 5.79 
Degrees of Freedom = 3 
21 
Ordering Medicare Equipment  OEI-02-97-00081  Table B-3 
Physician Specialty 
Respondents  Non-Respondents  Total  Response 
Rate 
General Practice  32752.73  10%  16918.96  12%  49671.69  66% 
General Surgery  11799.07  4%  7418.73  5%  19217.80  61% 
Cardiology  8091.05  2%  3659.92  3%  11750.97  69% 
Family Practice  53930.38  17%  25022.69  17%  78953.07  68% 
Internal Medicine  96206.08  30%  55235.16  38%  151441.24  64% 
Ophthalmology  18632.00  6%  1199.24  1%  19831.24  94% 
Orthopedic Surgery  12230.46  4%  4213.56  3%  16444.02  74% 
PMR  7560.38  2%  3440.45  2%  11000.83  69% 
Pulmonary Disease  31448.39  10%  7993.13  6%  39441.52  80% 
Other  53159.64  15%  19448.40  13%  72608.04  73% 
Total  325810.18  100%  144550.24  100%  470360.42  69% 
CHI-SQUARE = 26.83 
Degrees of Freedom = 9 
Tables B-1 and B-2 show no statistically significant differences between respondents and 
non-respondents for geographic region and Durable Medical Equipment Regional Carrier. 
In order for the results to be statistically significant at the 95 percent confidence level, the 
Chi-square value must be higher than 7.81 with 3 degrees of freedom. 
Table B-3 shows a statistically significant difference between respondents and non-
respondents with respect to type of physician specialty.  A Chi-square value higher than 
16.9 with 9 degrees of freedom suggests that physician specialty may influence whether or 
not a physician responded to the questionnaire.  In order to test whether this difference 
introduced any bias, we analyzed the rates of overall satisfaction with the Medicare 
process for ordering medical equipment and supplies, for differences between internal 
medicine and all other physician specialties.  We analyzed physician satisfaction in this way 
because internal medicine demonstrated a high percentage of the overall non-respondents. 
No significant difference exists as Table B-4 illustrates below. 
22 
Ordering Medicare Equipment  OEI-02-97-00081  Table B-4 
Satisfaction: Internal Medicine vs. All Other Specialties 
Respondents  Non-Respondents  Total  Satisfaction 
Rate 
Internal Medicine  60300.52  30%  17419.68  28%  77720.20  78% 
All Other  136870.41  70%  45193.21  72%  182063.62  75% 
Specialties 
Total  197170.93  100%  62612.89  100%  259783.82  76% 
CHI-SQUARE = 0.35 
Degrees of Freedom = 1 
Tables B-1, B-2, and B-4 show no statistically significant differences between respondents 
and non-respondents for any of the variables tested.  Given the results of this analysis, we 
believe that the inspection findings fairly represent the experience and opinions of 
physicians to whom the questionnaires were sent.  We therefore believe that our survey 
results can be generalized to the universe of physicians who ordered Medicare medical 
equipment and supplies during 1996. 
23 
Ordering Medicare Equipment  OEI-02-97-00081  APPENDIX C 
Statistical Tests for Key Findings 
We computed Chi-square values for differences in physicians overall satisfaction for eight 
variables.  All variables were analyzed at the 95 percent confidence level.  As shown in 
Table C-1 below, some variables demonstrate statistically significant satisfaction 
differences and some variables do not.  The direction of the differences below are 
discussed in the findings of this report. 
Table C-1 
Chi-Square Values for Testing Significance of Differences in Satisfaction 
Variable  Degrees of  Chi-Square  Significant Satisfaction 
Freedom  Difference 
Physician Specialty  9  22.37  Yes 
Provided Sufficient Criteria  1  15.71  Yes 
for Ordering 
Problems When Ordering  1  4.57  Yes 
Refused to Sign a CMN  1  11.21  Yes 
CMN Effective to Assure  1  73.97  Yes 
Proper Utilization 
DMERC  3  1.85  No 
Geographic Region  3  1.69  No 
CMN Requirement  1  0.01  No 
24 
Ordering Medicare Equipment  OEI-02-97-00081  APPENDIX D 
OFFICE OF 
INSPECTOR 
GENERAL 
SSPPEECCIIAALL  FFRRAAUUDD  AALLEERRTT

PHYSICIAN LIABILITY FOR CERTIFICATIONS IN THE 
PROVISION OF MEDICAL EQUIPMENT AND SUPPLIES AND 
HOME HEALTH SERVICES 
January 1999 
T
he Office of Inspector General (OIG) was established at the Department of Health
and Human Services by Congress in 1976 to identify and eliminate fraud, waste, and 
abuse in the Departments programs and to promote efficiency and economy in 
departmental operations.  The OIG carries out this mission through a nationwide program 
of audits, inspections, and investigations. 
To reduce fraud and abuse in the Federal health care programs, including Medicare and 
Medicaid, the OIG actively investigates fraudulent schemes that obtain money from these 
programs and, when appropriate, issues Special Fraud Alerts that identify segments of the 
health care industry that are particularly vulnerable to abuse.  Copies of all OIG Special 
Fraud Alerts are available on the internet at: 
http://www.dhhs.gov/progorg/oig/frdalrt/index.htm 
We are issuing this Fraud Alert because physicians may not appreciate the legal and 
programmatic significance of certifications they make in connection with the ordering of 
certain items and services for their Medicare patients.  While the OIG believes that the 
actual incidence of physicians intentionally submitting false or misleading certifications 
of medical necessity for durable medical equipment or home health care is relatively 
infrequent, physician laxity in reviewing and completing these certifications contributes 
to fraudulent and abusive practices by unscrupulous suppliers and home health providers. 
We urge physicians and their staff to report any suspicious activity in connection with the 
solicitation or completion of certifications to the OIG. 
Physicians should also be aware that they are subject to substantial criminal, civil, and 
administrative penalties if they sign a certification knowing that the information relating 
25 
Ordering Medicare Equipment  OEI-02-97-00081  to medical necessity is false, or with reckless disregard as to the truth of the information 
being submitted.  While a physicians signature on a false or misleading certification 
made through  mistake, simple negligence, or inadvertence will not result in personal 
liability, the physician may unwittingly be facilitating the perpetration of fraud on 
Medicare by suppliers or providers.  Accordingly, we urge all physicians to review and 
familiarize themselves with the information in this Fraud Alert.  If a physician has any 
questions as to the application of these requirements to specific facts, the physician 
should contact the appropriate Medicare Fiscal Intermediary or Carrier. 
THE IMPORTANCE OF PHYSICIAN CERTIFICATION FOR MEDICARE 
T
he Medicare program only pays for health care services that are medically necessary.
In determining what services are medically necessary, Medicare primarily relies on 
the professional judgment of the beneficiarys treating physician, since he or she knows 
the patients history and makes critical decisions, such as admitting the patient to the 
hospital; ordering tests, drugs, and treatments; and determining the length of treatment. 
In other words, the physician has a key role in determining both the medical need for, and 
utilization of, many health care services, including those furnished and billed by other 
providers and suppliers. 
Congress has conditioned payment for many Medicare items and services on a 
certification signed by a physician attesting that the item or service is medically 
necessary.  For example,  physicians are routinely required to certify to the medical 
necessity for any service for which they submit bills to the Medicare program. 
Physicians also are involved in attesting to medical necessity when ordering services or 
supplies that must be billed and provided by an independent supplier or provider. 
Medicare requires physicians to certify to the medical necessity for many of these items 
and services through prescriptions, orders, or, in certain specific circumstances, 
Certificates of Medical Necessity (CMNs).  These documentation requirements 
substantiate that the physician has reviewed the patients condition and has determined 
that services or supplies are medically necessary. 
Two areas where the documentation of medical necessity by physician certification plays 
a key role are (i) home health services and (ii) durable medical equipment (DME). 
Through various OIG audits, we have discovered that physicians sometimes fail to 
discharge their responsibility to assess their patients conditions and need for home health 
care.  Similarly, the OIG has found numerous examples of physicians who have ordered 
DME or signed CMNs for DME without reviewing the medical necessity for the item or 
even knowing the patient. 
PHYSICIAN CERTIFICATION FOR HOME HEALTH SERVICES 
26 
Ordering Medicare Equipment  OEI-02-97-00081  M
edicare will pay a Medicare-certified home health agency for home health care
provided under a physicians plan of care to a patient confined to the home. 
Covered services may include skilled nursing services, home health aide services, 
physical and occupational therapy and speech language pathology, medical social 
services, medical supplies (other than drugs and biologicals), and DME. 
As a condition for payment, Medicare requires a patients treating physician to certify 
initially and recertify at least every 62 days (2 months) that: 
#  the patient is confined to the home; 
#	 the individual needs or needed (i) intermittent skilled nursing care; (ii) speech or 
physical therapy or speech-language pathology services; or (iii) occupational 
therapy or a continued need for occupational therapy (payment for occupational 
therapy will be made only upon an initial certification that includes care under (i) 
or (ii) or a recertification where the initial certification included care under (i) or 
(ii)); 
#	 a plan of care has been established and periodically reviewed by the physician; 
and 
#	 the services are (were) furnished while the patient is (was) under the care of a 
physician. 
The physician must order the home health services, either orally or in writing, prior to the 
services being furnished.  The physician certification must be obtained at the time the 
plan of treatment is established or as soon thereafter as possible.  The physician 
certification must be signed and dated prior to the submission of the claim to Medicare. 
If a physician has any questions as to the application of these requirements to specific 
facts, the physician should contact the appropriate Medicare Fiscal Intermediary or 
Carrier. 
PHYSICIAN ORDERS AND CERTIFICATES OF MEDICAL NECESSITY FOR 
DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND 
SUPPLIES FOR HOME USE 
D
ME is equipment that can withstand repeated use, is primarily used for a medical
purpose, and is not generally used in the absence of illness or injury.  Examples 
include hospital beds, wheelchairs, and oxygen delivery systems.  Medicare will cover 
medical supplies that are necessary for the effective use of DME, as well as surgical 
dressings, catheters, and ostomy bags.  However, Medicare will only cover DME and 
supplies that have been ordered or prescribed by a physician.  The order or prescription 
27 
Ordering Medicare Equipment  OEI-02-97-00081  must be personally signed and dated by the patients treating physician. 
DME suppliers that submit bills to Medicare are required to maintain the physicians 
original written order or prescription in their files.  The order or prescription must 
include: 
#  the beneficiarys name and full address; 
#  the physicians signature; 
#  the date the physician signed the prescription or order; 
#  a description of the items needed; 
#  the start date of the order (if appropriate); and 
#	 the diagnosis (if required by Medicare program policies) and a realistic estimate of 
the total length of time the equipment will be needed (in months or years). 
For certain items or supplies, including supplies provided on a periodic basis and drugs, 
additional information may be required.  For supplies provided on a periodic basis, 
appropriate information on the quantity used, the frequency of change, and the duration 
of need should be included.  If drugs are included in the order, the dosage, frequency of 
administration, and, if applicable, the duration of infusion and concentration should be 
included. 
Medicare further requires claims for payment for certain kinds of DME to be 
accompanied by a CMN signed by a treating physician (unless the DME is prescribed as 
part of a plan of care for home health services).  When a CMN is required, the provider 
or supplier must keep the CMN containing the treating physicians original signature and 
date on file. 
Generally, a CMN has four sections: 
#	 Section A contains general information on the patient, supplier, and physician. 
Section A may be completed by the supplier. 
#	 Section B contains the medical necessity justification for DME.  This cannot be 
filled out by the supplier.  Section B must be completed by the physician, a non-
physician clinician involved in the care of the patient, or a physician employee. 
If the physician did not personally complete section B, the name of the person who 
did complete section B and his or her title and employer must be specified. 
#  Section C contains a description of the equipment and its cost.  Section C is 
28 
Ordering Medicare Equipment  OEI-02-97-00081  completed by the supplier. 
#	 Section D is the treating physicians attestation and signature, which certifies that 
the physician has reviewed sections A, B, and C of the CMN and that the 
information in section B is true, accurate, and complete.  Section D must be 
signed by the treating physician.  Signature stamps and date stamps are not 
acceptable. 
By signing the CMN, the physician represents that: 
#	 he or she is the patients treating physician and the information regarding the 
physicians address and unique physician identification number (UPIN) is correct; 
#	 the entire CMN, including the sections filled out by the supplier, was completed 
prior to the physicians signature; and 
#	 the information in section B relating to medical necessity is true, accurate, and 
complete to the best of the physicians knowledge. 
IMPROPER PHYSICIAN CERTIFICATIONS FOSTER FRAUD 
U
nscrupulous suppliers and providers may steer physicians into signing or authorizing
improper certifications of medical necessity.  In some instances, the certification 
forms or statements are completed by DME suppliers or home health agencies and 
presented to the physician, who then signs the forms without verifying the actual need for 
the items or services.  In many cases, the physician may obtain no personal benefit when 
signing these unverified orders and is only accommodating the supplier or provider. 
While a physicians signature on a false or misleading certification made through 
mistake, simple negligence, or inadvertence will not result in personal liability, the 
physician may unwittingly be facilitating the perpetration of fraud on Medicare by 
suppliers or providers.  When the physician knows the information is false or acts with 
reckless disregard as to the truth of the statement, such physician risks criminal, civil, and 
administrative penalties. 
Sometimes, a physician may receive compensation in exchange for his or her signature. 
Compensation can take the form of cash payments, free goods, or any other thing of 
value.  Such cases may trigger additional criminal and civil penalties under the anti-
kickback statute. 
The following are examples of inappropriate certifications uncovered by the OIG in the 
course of its investigations of fraud in the provision of home health services and medical 
equipment and supplies: 
29 
Ordering Medicare Equipment  OEI-02-97-00081  #	 A physician knowingly signs a number of forms provided by a home health agency 
that falsely represent that skilled nursing services are medically necessary in order 
to qualify the patient for home health services. 
#	 A physician certifies that a patient is confined to the home and qualifies for home 
health services, even though the patient tells the physician that her only restrictions 
are due to arthritis in her hands, and she has no restrictions on her routine 
activities, such as grocery shopping. 
#	 At the prompting of a DME supplier, a physician signs a stack of blank CMNs for 
transcutaneous electrical nerve stimulators (TENS) units.  The CMNs are later 
completed with false information in support of fraudulent claims for the 
equipment.  The false information purports to show that the physician ordered and 
certified to the medical necessity for the TENS units for which the supplier has 
submitted claims. 
#	 A physician signs CMNs for respiratory medical equipment falsely representing 
that the equipment was medically necessary. 
#	 A physician signs CMNs for wheelchairs and hospital beds without seeing the 
patients, then falsifies his medical charts to indicate that he treated them. 
#	 A physician accepts anywhere from $50 to $400 from a DME supplier for each 
prescription he signs for oxygen concentrators and nebulizers. 
POTENTIAL CONSEQUENCES FOR UNLAWFUL ACTS 
A
physician is not personally liable for erroneous claims due to mistakes,
inadvertence, or simple negligence.  However, knowingly signing a false or 
misleading certification or signing with reckless disregard for the truth can lead to serious 
criminal, civil, and administrative penalties including: 
#  criminal prosecution; 
#  fines as high as $10,000 per false claim plus treble damages; or 
#	 administrative sanctions including:  exclusion from participation in Federal health 
care programs, withholding or recovery of payments, and loss of license or 
disciplinary actions by state regulatory agencies. 
Physicians may violate these laws when, for example: 
#  they sign a certification as a courtesy to a patient, service provider, or DME 
30 
Ordering Medicare Equipment  OEI-02-97-00081  supplier when they have not first made a determination of medical necessity; 
#	 they knowingly or recklessly sign a false or misleading certification that causes a 
false claim to be submitted to a Federal health care program; or 
#	 they receive any financial benefit for signing the certification (including free or 
reduced rent, patient referrals, supplies, equipment, or free labor). 
Even if they do not receive any financial or other benefit from providers or suppliers, 
physicians may be liable for making false or misleading certifications. 
WHAT TO DO IF YOU HAVE INFORMATION ABOUT FRAUD AND ABUSE 
AGAINST MEDICARE OR MEDICAID PROGRAMS 
If you have information about physicians, home health agencies, or medical equipment 
and supply companies engaging in any of the activities described above, contact any of 
the regional offices of the Office of Investigations of the Office of Inspector General, 
U.S. Department of Health and Human Services, at the following locations: 
Field Offices  States Served  Telephone 
Boston	 MA, VT ,NH, ME,  617-565-2664 
RI, CT 
New York  NY, NJ, PR, VI  212-264-1691 
Philadelphia	 PA, MD, DE, WV,  215-861-4586 
VA, DC 
Atlanta	 GA, KY, NC, SC,  404-562-7603 
FL, TN, AL, MS 
Chicago  IL, MN, WI, MI,  312-353-2740 
IN, OH, IA, MO 
Dallas  TX, NM, OK, AR,  214-767-8406 
LA, CO, UT, WY, 
MT, ND, SD, NE, KS 
31 
Ordering Medicare Equipment  OEI-02-97-00081  Los Angeles  AZ, NV, So. CA  714-246-8302 
San Francisco  No. CA, AK, HI  415-437-7961 
OR, ID, WA 
32 
Ordering Medicare Equipment  OEI-02-97-00081  APPENDIX E 
Comments on the Draft Report

In this appendix, we present in full the comments from the Health Care Financing 
Administration. 
33 
Ordering Medicare Equipment  OEI-02-97-00081  34 
Ordering Medicare Equipment  OEI-02-97-00081  35 
Ordering Medicare Equipment  OEI-02-97-00081  36 
Ordering Medicare Equipment  OEI-02-97-00081