Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

FEBRUARY 1999 

OEI-02-97-00080 

ORDERING MEDICARE EQUIPMENT 

AND SUPPLIES 

Physician Patient Relationship 
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 
EXECUTIVE SUMMARY 

PURPOSE 

To determine whether the relationship between the physician and the patient affects the 

certification for Medicare medical equipment and supplies 

BACKGROUND 

We are undertaking two studies to look at the role of the physician in certifying nonphysician services. The first report, “Ordering Medicare Equipment and Supplies, 

Physician Perspectives” OEI-02-97-00081 is about physicians’ perceptions of the 

certification process for durable medical equipment, prosthetics, orthotics, and supplies 

(DMEPOS). This second report looks at the relationship between the physician and the 

patient and its’ effect on the certification of medical equipment and supplies. 

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. This report is based on the analysis of questionnaires 

sent to physicians who certified a sample of 1,000 medical equipment or supply items, a 

review of claims histories and medical records associated with those 1,000 medical 

equipment and supply items, telephone interviews with a sub-sample of 200 patients, a 

review of the certificates of medical necessity or physician’s orders submitted by the 

suppliers and interviews with the 4 durable medical equipment regional carriers. 

FINDINGS 

Most Medical Equipment and Supplies are Prescribed by the Treating Physicians, 

But Some Problems Are Identified 

The referring physicians for 89 percent of the items billed knew and treated the patients 

for whom they ordered medical equipment and supplies. Of the remaining 11 percent we 

determined that almost one half appear to be coding errors with the unique physician’s 

identifying number. In the remaining 6 percent of cases, the physician reported not 

knowing the patient without explanation. Additionally, 13 percent of physicians who say 

they knew the patient did not order the equipment or supplies. Ninety percent of patients 

Ordering Medicare Equipment 1 OEI-02-07-00080 
interviewed who received the medical equipment and supplies report being treated by the 

referring physician during the study period. 

Medicare Payments Were Questionable for Fourteen Percent of the Sample 

Medical Equipment and Supplies 

In nine percent of the medical records we received there was no documentation of the 

need for the equipment or supplies billed. In another four percent patients required the 

equipment when it was originally ordered but no longer needed it, patients receiving 

diabetic supplies were not insulin dependent as required by Medicare in 1996, billings 

were after the date of the patient’s death, or equipment or supplies were inappropriately 

billed to skilled nursing facilities. In one percent of the records there was sufficient 

evidence to fully prove that the equipment or supplies were unnecessary. 

Medical records are more often questioned when physicians report not ordering the 

equipment or supplies and less likely to be questioned when there was a recent encounter 

between the physician and patient. 

The questionable records represent $414 million of Medicare payments. This is a 

conservative amount because it is based on a review of the 530 of 1000 records we 

received. We did not receive an additional 470 records that we requested. The failure of 

providers to supply us with these records makes it likely that the payment error rates were 

at least equal to or may even have been greater than those we received. Thus the actual 

dollar amount of questionable Medicare payments is likely to be significantly higher than 

the amount we calculated. 

Vulnerabilities Exist in the Medical Equipment and Supply Ordering Process 

Currently Medicare regulations do not require the patient’s diagnosis, the physician’s 

name, identifying number, or speciality on the claim. Because there are diagnosis or 

physician speciality driven policies, the physician’s name and identifying number are 

important in order to contact the referring physician for any information about the patient 

or to review a medical record for the appropriateness of equipment or supplies. The lack 

of an ongoing medical relationship between the durable medical equipment regional 

carriers and physicians hampers the educational efforts about supplies and equipment. The 

durable medical equipment carrier does not have physician information readily available, 

and is not responsible for educating the physicians about the Medicare requirements for 

medical equipment or supplies. 

Ordering Medicare Equipment 2 OEI-02-07-00080 
RECOMMENDATIONS 

We found that when the referring physician knew the patient, more appropriate medical 

equipment and supplies were ordered. Therefore we support the Health Care Financing 

Administration in its’ requirement that the referring physician be a physician who has 

treated the patient and recommend that: 

< the physician who orders the equipment or supplies be required to treat the patient 

prior to the order and 

< a systematic process be developed to assure that the supplier submits a new CMN 

or order to the DMERC when the physician changes, the equipment or supply or 

the medical need for the equipment or supply changes. 

We recognize that as a result of the Balanced Budget Act of 1997, physicians are required 

to provide diagnostic information to suppliers and the suppliers provide this information 

on claims for medical supplies and equipment when the DMERC has a medical review 

policy requiring such diagnostic information. We support this, but recommend that: 

< the referring physician’s name and specialty, the patient’s related diagnostic 

information be required on all claims for medical equipment and supplies. 

This report also supports the recommendation in our report entitled “Ordering Medicare 

Equipment and Supplies, Physician’s Perspectives” OEI-02-97-0081. This report 

recommended that the Health Care Financing Administration strengthen its efforts to 

educate physicians regarding their ordering of medical equipment and supplies and 

suggested the following approaches: 

< 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 

Ordering Medicare Equipment 3 OEI-02-07-00080 
physicians include the coverage and payment rules and cost of equipment for the 

specific equipment or supplies ordered. 

We will refer all unnecessary and questionable cases and those where the physician did not 

see the patient or did not order the equipment or supplies to the appropriate Durable 

Medical Equipment Regional Carrier for further review. 

COMMENTS 

We received comments on the draft report from HCFA. They generally concur with our 

recommendations. Based on their comments we changed one of the suggested approaches 

in our recommendations on providing physicians with information about ordering medical 

equipment and supplies by expanding it to apply to all physicians not just new ones. The 

HCFA’s 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 

recommendations to clarify that the information about coverage and payment rules had to 

do with the specific equipment and supplies ordered rather than general guidelines. 

Ordering Medicare Equipment 4 OEI-02-07-00080 
TABLE OF CONTENTS 

PAGE

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

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

FINDINGS

Most physicians treat the patient ......................................... 12

Equipment and Supplies unnecessary and questionable ......................... 13

DMERCs note vulnerabilities ............................................ 15

RECOMMENDATIONS ................................................... 17

APPENDICES

A: Confidence intervals for key questions ................................... 19

B: Medical review dollar projections ...................................... 22

C: Tests for key findings ............................................... 24

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

E: Comments ........................................................ 33

Ordering Medicare Equipment 5 OEI-02-07-00080 
INTRODUCTION 

PURPOSE 

To determine whether the relationship between the physician and the patient affects the 

certification for Medicare medical equipment and supplies. 

BACKGROUND 

We are undertaking two studies to look at the role of the physician in certifying nonphysician services. The first report, “Ordering Medicare Equipment and Supplies, 

Physician Perspectives” OEI-02-97-00081 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 and wound care supplies, and enteral and parenteral nutrition. For the 

purposes of our reports we refer to DMEPOS as medical equipment and supplies. In the 

first report we found that physicians are generally satisfied with the process, but would 

like it to be easier and less time consuming. They would also like more detailed rules and 

specific criteria regarding Medicare coverage and eligibility for medical equipment and 

supplies. This second report looks at the relationship between the physician and the 

patient and its’ effect on the certification of medical equipment and supplies. 

In general, Medicare recognizes the physician as the key figure in determining the 

appropriate utilization of medical services. As one component of this process, 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 required 

physician certification and re-certification statements, and for keeping them on file for 

verification. 

Medicare Expenditures for Medical Equipment and Supplies 

According to published Health Care Financing Administration (HCFA) statistics, in 1996, 

Medicare paid an estimated $4.8 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, home health agencies, and skilled nursing facilities. Part B, supplementary 

medical insurance, covers a wide array of non-institutionalized care. These include 

Ordering Medicare Equipment 6 OEI-02-07-00080 
physicians services, medical equipment and supplies, outpatient hospital services, 

diagnostic laboratory tests, x-rays and ambulance services. 

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 physician visits are considered carriers. Intermediaries 

and carriers are also responsible to assure that Medicare coverage requirements are met 

before approving payment. 

Medicare Durable Medical Equipment Regional Carriers (DMERCs) 

In October 1993 HCFA began processing claims for medical equipment and supplies 

through 4 durable medical equipment regional carriers (DMERCs). These 4 carriers are 

responsible for all 50 States, the District of Columbia, and Puerto Rico. These entities are 

responsible for ensuring that coverage requirements for medical equipment and supplies 

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 covered by 

Part B and processed by the DMERCs. 

Certification of Durable Medical Equipment 

Medicare pays for medical equipment and supplies that are ordered or prescribed by a 

treating physician and is 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 that they bill to Medicare. The 

supplier usually puts the name and unique physician identification number (UPIN) of the 

referring physician and the patient’s diagnosis related to the equipment or supplies ordered 

on the claim, but the claim will be paid without this information. 

In addition to HCFA's requirement that suppliers are required to have a physician's order 

or prescription on file for all claims for medical equipment and supplies submitted for 

reimbursement, HCFA requires that certain equipment and supplies have a document 

called a certificate of medical necessity (CMN) stating 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, which process the claims for 

medical equipment and supplies. 

Some of the items within the following 14 groups require a CMN: 

! hospital beds ! motorized wheelchairs 

! support surfaces ! manual wheelchairs 

! lymphedema pumps ! osteogenesis stimulators 

Ordering Medicare Equipment 7 OEI-02-07-00080 
! 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 

The CMNs were revised in October of 1995. They were standardized and reformatted by 

HCFA and the DMERCs. Each of the aforementioned equipment and supply groups now 

have their own CMN form. 

CMNs now have four sections: A-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 suppliers. The Durable Medical Equipment Regional Carriers prefer that a 

clinician fills out Section B, but there is no specific requirement to that effect. Section C 

contains a narrative description of all items ordered, the supplier’s charge and the 

Medicare fee schedule allowance. Section D must be signed by the physician certifying 

the medical necessity of the device. This certifying physician cannot have any financial or 

contractual relationship with the supplier of the item. 

The Omnibus Budget Reconciliation Act (OBRA) of 1990 prohibited suppliers from filling 

out the CMNs themselves. The HCFA interpreted this to mean that suppliers could fill 

out only the administrative portion of the CMN. In addition, in instances where the 

supplier initiates the process by filling out the administrative portion, HCFA requires that 

they must also send a letter to the physician indicating what their charge and Medicare's 

allowed amount for the item is. 

Balanced Budget Act of 1997 

The Balanced Budget Act of 1997 requires that when an item is ordered by a physician, 

but furnished by another entity such as a supplier, the entity furnishing the item, that is the 

supplier, must provide diagnostic or other medical information in order for payment to be 

made to the supplier. The physician must provide this information to the supplier when 

the item is ordered. This is effective January 1, 1998. Physicians are required to provide 

this diagnostic information when ordering supplies when the carrier has put in place a local 

medical review policy requiring such diagnostic information from the supplier. 

OIG Activities 

There have been many OIG efforts related to the utilization of non-physician services. 

The following two studies have addressed 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 

Ordering Medicare Equipment 8 OEI-02-07-00080 
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 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 report 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 HCFA’s 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 have no such 

requirement. We then further stratified the CMN codes between oxygen and non-oxygen 

items. This ensured that oxygen related items were not over-represented in our sample. 

Within the non-CMN stratum, we selected medical equipment and supply items from the 

procedure codes used for billing (HCPCS) 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 items in 1996 and 99 percent of the total 

monetary amount 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. 

From this sampling, we identified the beneficiary, his/her diagnosis, the supplier, the place 

of service, the certifying physician, and his/her specialty. 

Beneficiary Histories 

Using the appropriate codes for physician visits and other medical equipment and supplies 

in the beneficiary billing histories, we determined whether the referring physician identified 

from our sampling had billed Medicare for any physician encounters in a 6 month period 

prior to date of the claim. We used this information as one source of the physician's prior 

treating relationship with the beneficiary. 

Ordering Medicare Equipment 9 OEI-02-07-00080 
Physician Survey and Medical Record Review 

We mailed a questionnaire to the 983 physicians certifying the equipment for the 1000 line 

items in our sample and asked them: if they have ever treated and how long they have 

known the beneficiaries for whom they certified these services; the date of their last visit 

with that beneficiary; and if they ordered the equipment or supplies. We received 695 

completed questionnaires from sample physicians. 

We also requested the 1000 relevant medical records for each of the 985 beneficiaries in 

our sample. We received 530 of the 1000 medical records requested from the physicians 

or from the facility where the physician told us the medical record was kept. We 

developed a screening instrument to review the medical records to determine whether the 

information provided supported the need for the medical equipment or supplies that was 

provided to the beneficiary. We used the HCFA requirements for reimbursing the 

particular equipment or supplies being reviewed to develop the screening instrument. This 

instrument was reviewed by the DMERCs and changed according to their suggestions. 

The screening was done by a registered nurse on the inspection team to determine whether 

information provided by the physician in the medical record supported the need for the 

medical equipment or supplies provided. The questionable medical records were referred 

to a DMERC and reviewed by their medical staff. 

We conducted a second and third mailing to non-respondents and 782 physicians 

responded to us in some form. Seven hundred and fifty-one physicians either sent in the 

questionnaire, a medical record, or both. Of the remaining 31 physicians, 20 notified us 

they are retired, and 11 directed us to a nursing home for the relevant patient information. 

The remaining physicians are non-respondents who we were either unable to locate or 

failed to respond. We were able to gather information in some form on all but 32 sample 

physicians. 

Suppliers 

We identified the suppliers for each of the beneficiaries in our sample and requested 

copies of the CMNs and/or physician orders for items supplied to those beneficiaries. We 

examined these forms to determine when they were signed and whether the physician who 

signed the CMN or ordered the item is also the referring physician in our sample. We 

received 920 returns from the suppliers. 

Durable Medical Equipment Regional Carrier (DMERC) Interviews 

We interviewed by telephone and on-site the appropriate carrier staff to determine how 

the physician certification requirements are overseen. We asked them to identify any 

existing prepayment screens and/or edits regarding physician authorization. We also 

Ordering Medicare Equipment 10 OEI-02-07-00080 
discussed their post-payment efforts in this area. Finally, we obtained and reviewed any 

policies or educational materials the carriers might have which address this issue. 

Beneficiary Survey 

We selected a random sub-sample of 200 beneficiaries for telephone interviews. These 

interviews included questions regarding: who initiated the provision of the service; 

whether, and how recently, the physician who had certified the service had treated the 

beneficiary; and whether the beneficiary had received and was satisfied with the overall 

process of obtaining the equipment. We contacted and interviewed 145 beneficiaries in 

the sub-sample. 

This inspection was conducted in accordance with the Quality Standards for 

Inspections issued by the President’s Council on Integrity and Efficiency. 

Ordering Medicare Equipment 11 OEI-02-07-00080 
FINDINGS 

Most medical equipment and supplies are prescribed by the 

treating physician, but some problems are identified 

Almost all physicians know the patient 

The referring physicians for 89 percent of the items billed knew and treated the patient for 

whom they ordered durable medical equipment and supplies. Of the remaining 11 percent 

we determined that almost half appear to be coding errors with the unique physician 

identification number (UPIN). Some of these UPIN problems include transposed numbers 

or numbers with the wrong prefix in the claim information. Often, the name of a 

completely different physician and an inappropriate specialty appear on the claim. 

With regard to the remaining cases (6 percent) the claim and the certificate of medical 

necessity or order have the physician’s name and signature but the physician reports not 

knowing the patient. This could occur for a number of reasons. The physician may not 

remember a patient who is seen in a location other than their office, such as a nursing 

home, because the records would be kept at the other site. It may have been a patient 

whom they treated years ago and ordered equipment or supplies that do not require recertification or the supplier may have signed the physician’s name to complete the form. 

Over one-half (52 percent) of the physicians who did not know the patient reside in 

California, Florida, and New York compared to 23 percent for all other States. Eighteen 

percent of these physicians are general surgeons, although this physician specialty 

comprises only 4 percent in the sample. There is no pattern relative to the kinds of 

supplies and equipment billed. 

Additionally, thirteen percent of physicians who say they knew the patient did not order 

the equipment or supplies. However, a review of the certificates of medical necessity or 

orders show that the physician’s name was the same in three out of four cases. This may 

occur for a number of reasons. The doctor may not remember the patient or another 

physician in the office or an office assistant may have ordered the equipment or supplies. 

Another possibility is that the supplier signed the CMN or order. 

Almost all patients know the physicians 

Ninety percent of the patients receiving medical equipment and supplies report being 

treated by the referring physician during the study period. The doctor was usually their 

regular physician (72 percent) who had treated them for several years. In many cases the 

patient continues to be treated by the physician. Ninety-six percent of the patients 

Ordering Medicare Equipment 12 OEI-02-07-00080 
confirmed receiving the medical equipment or supplies ordered in our sample. More than 

three-fourths (79 percent) of beneficiaries who received medical equipment or supplies 

continue to use them. 

Many physicians did not treat the patient within 6 months of receiving the 

equipment 

A review of Medicare data showed that 39 percent of physicians did not bill Medicare for 

a physician visit 6 months prior to the claim. Those physicians who had no encounter in 

the billing history were less likely to submit medical records than those with an encounter. 

Sixty-seven percent of those physicians who did not show an encounter sent in medical 

records compared to 85 percent who had an encounter. 

We attempted to contact those patients whose billing history showed no prior physician 

encounter and whose physician did not send in a medical record or questionnaire. We 

will refer to this group as non-respondents. While only 19 of 51 patients were contacted, 

18 out of 19 reported knowing the physician on the claim. Only one patient reported not 

knowing the physician on the claim. While wheelchairs and wheelchair accessories 

represent 12 percent of our total sample, they comprise 18 percent of the non-respondent 

group. Hospital beds represent 5 percent of our sample and 13 percent of the nonrespondent group. 

Medicare payments were questionable for fourteen percent 

of the sample medical equipment and supplies 

In 9 percent of the medical records we received there was no documentation of the need 

for the equipment or supplies billed. There was no diagnosis or indication in the medical 

record that the item was ordered or received, although the diagnosis on the claim might 

have been appropriate. In many cases the documentation was scanty, seemed incomplete, 

or was sometimes difficult to read. 

In another 4 percent of records that were questionable the patient required the equipment 

when it was originally ordered, but according to the medical record the patient no longer 

had a need for it. An example is a patient who had a fractured hip and needed a 

wheelchair when she first came home from the hospital in 1995, but at the time of our 

sample billing the patient was walking independently on all surfaces according to the 

record. Nevertheless Medicare continued to pay a monthly rental for a wheelchair for her. 

Other patients were receiving diabetic supplies and were not insulin dependent as required 

by Medicare in 1996. Some items were billed after the date of the patient’s death, and 

some were inappropriately billed to patients in skilled nursing facilities. See Appendix B 

for further analysis. 

Ordering Medicare Equipment 13 OEI-02-07-00080 
Despite a high non-response rate, wheelchairs and hospital beds represented a large 

proportion of questionable medical records. While wheelchairs and wheelchair accessories 

represent 12 percent of our total sample, they are 27 percent of the questionable medical 

records. Hospital beds represent 5 percent of our sample and 13 percent of the 

questionable records. Both wheelchairs and hospital beds are expensive items and are 

usually rented. They do not require re-certification unless the physician or the need for the 

equipment changes. There appears to be no established notification process when a 

patient may no longer fulfill the Medicare requirements for the item. 

In 1 percent of the medical records there was sufficient evidence to fully prove that the 

equipment or supplies were unnecessary. All but one of the medically unnecessary records 

involved oxygen. In these cases there was no indication in the medical records that the 

patients had any breathing problems or that oxygen was being used. The equipment in the 

remaining case was determined unnecessary because the physician informed us that the air 

pressure mattress was never ordered by him and the patient has no history of bedsores. 

The medical record read, ”Patient up and about as necessary.” According to the record, 

the only equipment ordered was a four pronged cane. 

Questionable records represent $414 million in Medicare payments 

The 14 percent of medical records that were questionable project to $414 million. Sixty 

million of the $414 million represent the 1 percent of the records where there was 

sufficient evidence to fully prove that the equipment or supplies were unnecessary. The 

$414 million is a conservative amount because it is based on a review of only those 530 of 

1000 records we received. We did not receive an additional 470 records that we 

requested. The failure of providers to supply us with these records makes it likely that the 

payment error rates were at least equal to or may even have been greater than those we 

received. Thus the actual dollar amount of questionable Medicare payments is likely to be 

significantly higher than the amount we calculated. 

Medical records are more likely to be questioned for physicians who report not 

ordering the equipment or supplies 

Of the physicians who said that they know the patient but did not order the equipment or 

supplies, 22 percent of the records were questionable or unnecessary. Of the physicians 

who report ordering the equipment, only 11 percent were questioned. This difference is 

significant at the 90 percent level of confidence. 

Medical records are less likely to be questioned when there was a recent 

encounter between the physician and patient 

Only 12 percent of the medical records were questioned when the physician saw the 

patient in 1996 or later. Twenty-seven percent of the records were questionable or 

Ordering Medicare Equipment 14 OEI-02-07-00080 
unnecessary when the physician reported not seeing the patient since 1995 or earlier. This 

difference is significant at the 90 percent level of confidence. 

Vulnerabilities exist in the medical equipment and supply 

ordering process 

Lack of patient’s diagnosis on the claim 

Currently Medicare regulations do not require that the patient’s diagnosis be included on 

the claim, although certain items do have diagnosis requirements to determine eligibility. 

In 1996, diabetic supplies required a diagnosis of insulin dependent diabetes in order to be 

paid, although as of January 1998 the insulin dependency has been removed. They also 

note that there are policies that require a patient diagnosis of obstructive sleep apnea 

before a continuous airway pressure device is eligible for payment. 

Some of the DMERCs suggested the use of more diagnosis driven claims. This would 

facilitate more accurate claims processing. In addition to the diagnosis on the claim, one 

DMERC medical director would like to see more preauthorization or approval prior to 

supplying the item especially in the area of wheelchairs and wheelchair accessories. 

Referring physician’s name or identifying number is not always on the claim 

There is no requirement that the referring physician’s name or identifying number (UPIN) 

appear on the claim and no systematic procedure exists to verify them. The DMERCs 

report that if the claim has the correct number of digits and a letter in the referring 

physician section, the number will be accepted and the claim processed. We found a 

number of different problems with the UPIN in our review. These include claims without 

any number so the referring physician could not be identified, the same number on both 

the claim and the CMN with different physicians’ names, transposed numbers or a prefix 

that gives us the name of a physician different from the patient’s physician, or a generic 

number that appears to indicate a hospital intern or resident. In all of these cases it is 

impossible to contact the referring physician for any information about the patient. One of 

the DMERCs indicated that if a physician is under sanctions, claims could be suspended by 

checking the UPIN number. In order to review a medical record for the appropriateness 

of the equipment or supplies ordered, the proper physician needs to be identified on the 

claim. 

It is also important to capture the referring physician’s specialty on the claim because 

Medicare only pays for some medical equipment and supplies when referred by certain 

physician specialties. For example, power-operated vehicles may be used as an electric 

wheelchair when prescribed by specialists in physical medicine, orthopedics, rheumatology 

or neurology. 

Ordering Medicare Equipment 15 OEI-02-07-00080 
Difficulty identifying patient place of residence 

The DMERCs indicated that there is no way to verify the place of service on the claim 

because the name of the facility is not required by Medicare. Certain medical equipment 

and supplies are not paid for in a skilled nursing facility. The medical review in this report 

indicated that some items were inappropriately billed to beneficiaries in skilled nursing 

facilities. These included wheelchairs and IV poles. The prospective payment system’s 

implementation in skilled nursing facilities in July of 1998 will include some supplies and 

equipment. It will be essential to know if a patient is in a skilled nursing facility in order to 

process claims correctly. 

Lack of ongoing medical relationship between DMERCS and physicians hampers 

educational efforts 

The DMERCs usually have no ongoing relationship with the referring physicians who sign 

the orders or CMNs. The suppliers have the responsibility to maintain the order or CMN 

on file and make them available to the DMERC for review. The DMERC does not have 

physician data readily available, and is not responsible for educating the physician about 

the criteria and eligibility requirements for medical equipment and supplies. One medical 

director indicated that the weak link in the process is the physician. One suggestion made 

by the DMERC medical staff is to have the criteria and eligibility requirements on the 

CMN which the physician would then review before signing the form. One DMERC 

attempted to use suppliers to distribute new policies to physicians but it did not work. 

Without direct access to the individual physicians, DMERCs must occasionally contact the 

appropriate Part B carriers to include new policies about supplies and equipment in their 

bulletins. Other DMERCs have used seminars, contacts with State Medical Societies, 

articles, and individual phone calls and letters to educate the physicians about medical 

equipment and supplies. 

Ordering Medicare Equipment 16 OEI-02-07-00080 
RECOMMENDATIONS 

We found that when the referring physician knew the patient, more appropriate medical 

equipment and supplies were ordered. Therefore we support the Health Care Financing 

Administration in its’ requirement that the referring physician be a physician who has 

treated the patient and recommend that: 

< the physician who orders the equipment or supplies be required to treat the patient 

prior to the order and 

< a systematic process be developed to assure that the supplier submits a new CMN 

or order to the DMERC when the physician changes, the equipment or supply or 

the medical need for the equipment or supply changes. 

We recognize that as a result of the Balanced Budget Act of 1997, physicians are required 

to provide diagnostic information to suppliers and the suppliers provide this information 

on claims for medical supplies and equipment when the DMERC has a medical review 

policy requiring such diagnostic information. We support this, but recommend that: 

< the referring physician’s name and specialty, the patient’s related diagnostic 

information be required on all claims for medical equipment and supplies. 

This report also supports the recommendation in our report entitled “Ordering Medicare 

Equipment and Supplies, Physician’s Perspectives” OEI-02-97-0081. This report 

recommended that the Health Care Financing Administration strengthen its efforts to 

educate physicians regarding their ordering of medical equipment and supplies and 

suggested the following approaches: 

< 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 for 

medical equipment and supplies; 

< providing all physicians with a contact person at the carriers to answer questions 

about equipment or supplies; and 

Ordering Medicare Equipment 17 OEI-02-07-00080 
Ordering Medicare Equipment 18 OEI-02-07-00080 
< assuring that all certificates of medical necessity sent from the suppliers to 

physicians include the coverage and payment rules and cost of equipment for the 

specific equipment or supplies ordered. 

We will refer all unnecessary and questionable cases and those where the physician did not 

see the patient or did not order the equipment or supplies to the appropriate Durable 

Medical Equipment Regional Carrier for further review. 

COMMENTS 

We received comments on the draft report from HCFA. They generally concur with our 

recommendations. Based on their comments we changed one of the suggested approaches 

in our recommendations on providing physicians with information about ordering medical 

equipment and supplies by expanding it to apply to all physicians not just new ones. The 

HCFA’s 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 

recommendations to clarify that the information about coverage and payment rules had to 

do with the specific equipment and supplies ordered rather than general guidelines. 

Ordering Medicare Equipment 19 OEI-02-07-00080 
APPENDIX A 

Confidence Intervals for Key Survey Questions

We calculated confidence intervals for 12 key questions from the physician questionnaires, 

beneficiary telephone surveys, medical records, certificates of medical necessity or orders, 

and beneficiary histories. The response estimate and 95 percent confidence interval are 

given for each of the following: 

Physician survey questions 

1. Is the patient referred to in the enclosed letter someone that you have ever treated? 

“Yes” response estimate: 89% 

Lower interval: 87% 

Upper interval: 92% 

2. Approximately when did you last treat this patient in person? 

“1996" or “1997" response estimate: 88% 

Lower interval: 85% 

Upper interval: 91% 

3. Approximately how long have you treated this patient? 

“More than one year” response estimate: 87% 

Lower interval: 84% 

Upper interval: 90% 

4. Did you order the equipment or supplies referred to in the enclosed letter? 

“Yes” response estimate: 82% 

Lower interval: 79% 

Upper interval: 86% 

Ordering Medicare Equipment 20 OEI-02-07-00080 
Beneficiary survey questions 

5. Have you ever been examined by this physician? 

“Yes” response estimate: 90% 

Lower interval: 96% 

Upper interval: 85% 

6. Did you receive the equipment or supplies? 

“Yes” response estimate: 96% 

Lower interval: 93% 

Upper interval: 100% 

7. Is the physician your regular doctor or specialist you saw for a particular reason? 

“Regular doctor” response estimate: 72% 

Lower interval: 64% 

Upper interval: 81% 

8. Did you see the physician in 1996? 

“Yes” response estimate: 94% 

Lower interval: 89% 

Upper interval: 99% 

Medical record information 

9. Overall were the equipment/supplies reasonable and necessary according 

to Medicare guidelines? 

“No” response estimate: 14% 

Lower interval: 11% 

Upper interval: 17% 

Certificate of medical necessity/physician’s order information 

10. Is the claim physician the same as the ordering physician? 

“Yes” response estimate: 83% 

Lower interval: 80% 

Upper interval: 85% 

Ordering Medicare Equipment 21 OEI-02-07-00080 
11. Is the date on the Certificate of Medical Necessity/Order before the claimed date? 

“Yes” response estimate: 70% 

Lower interval: 67% 

Upper interval: 73% 

Beneficiary history information 

12. Was there billing by the referring physician in the six month period prior to the 

date 

the equipment was ordered? 

“Yes” response estimate: 61% 

Lower interval: 58% 

Upper interval: 64% 

Ordering Medicare Equipment 22 OEI-02-07-00080 
APPENDIX B 

Medical Review Dollar Projections

We used the HCFA requirements for reimbursement and a screening instrument to 

determine whether information provided by the physician in the medical record supported 

the need for the medical equipment or supplies provided. A registered nurse on the team 

completed a medical review screening instrument. Questionable cases were referred to 

and reviewed by a DMERC medical staff. Fourteen percent of medical equipment and 

supplies in our sample are medically unnecessary or questionable. The weighted allowable 

monetary amount projects to $414,396,000 + or - $120,326,900 at the 95 percent 

confidence level. See Table I below. 

Table I 

Medically Unnecessary or Questionable Dollar Projections 

Sample Size 530 medical record 

responses 

Weighted Size 487,200 

Total $414,396,000 

Standard Error Total $61,391,200 

95% Confidence Interval $120,326,900 

Lower limit $294,069,100 

Upper limit $534,722,900 

Seventy-nine medical equipment or supply items were deemed questionable or medically 

unnecessary. Wheelchairs and wheelchair accessories comprised over one-quarter of all 

questionable records. Additionally, oxygen and oxygen accessories comprised 22 percent 

of all questionable records. Table II below illustrates the breakdown of all questionable or 

medically unnecessary equipment or supplies. 

Ordering Medicare Equipment 23 OEI-02-07-00080 
Table II 

Unnecessary or Questionable Medical Equipment and Supplies 

Equipment or Supply Number Percent of Questionable 

Wheelchairs and accessories 21 27% 

Oxygen and accessories 17 22% 

Diabetic supplies 10 13% 

Hospital beds 10 13% 

Other 7 9% 

Enteral feeding supplies 5 6% 

IV poles 3 4% 

Alternating pressure mattress 2 3% 

Commode chair 2 3% 

Ostomy supplies 2 3% 

Total 79 100% 

Ordering Medicare Equipment 24 OEI-02-07-00080 
APPENDIX C 

Statistical Tests for Key Findings

We computed Chi-square values for three key findings. All variables were analyzed at the 

90 percent level of confidence. As shown in Table I below, all variables demonstrate 

statistically significant differences. The direction of the differences below are discussed in 

the findings of this report. 

Table I 

Chi-Square Values for Testing Significant Differences 

Variables Degrees of 

Freedom 

Chi-Square Significant 

Difference 

Beneficiary History vs 

Medical Records Received 

2 23.95 *Yes 

Questionable Items vs When Did 

the Physician Last See the Patient 

1 3.34 Yes 

Questionable Items vs 

Did the Physician Order 

1 3.26 Yes 

*There is a significant difference at the 95 percent level of confidence 

Ordering Medicare Equipment 25 OEI-02-07-00080 
SPECIAL FRAUD ALERT

APPENDIX D 

OFFICE OF 

INSPECTOR 

GENERAL 

PHYSICIAN LIABILITY FOR CERTIFICATIONS IN THE 

PROVISION OF MEDICAL EQUIPMENT AND SUPPLIES AND 

HOME HEALTH SERVICES 

January 1999 

he Office of Inspector General (OIG) was established at the Department of Health Tand Human Services by Congress in 1976 to identify and eliminate fraud, waste, and 

abuse in the Department’s 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. 

Ordering Medicare Equipment 26 OEI-02-07-00080 
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 

to medical necessity is false, or with reckless disregard as to the truth of the information 

being submitted. While a physician’s 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 

he Medicare program only pays for health care services that are medically necessary. TIn determining what services are medically necessary, Medicare primarily relies on 

the professional judgment of the beneficiary’s treating physician, since he or she knows 

the patient’s 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 patient’s 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. 

Ordering Medicare Equipment 27 OEI-02-07-00080 
PHYSICIAN CERTIFICATION FOR HOME HEALTH SERVICES 

Medicare will pay a Medicare-certified home health agency for home health careprovided under a physician’s 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 patient’s 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 

ME is equipment that can withstand repeated use, is primarily used for a medical Dpurpose, and is not generally used in the absence of illness or injury. Examples 

include hospital beds, wheelchairs, and oxygen delivery systems. Medicare will cover 

Ordering Medicare Equipment 28 OEI-02-07-00080 
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 

must be personally signed and dated by the patient’s treating physician. 

DME suppliers that submit bills to Medicare are required to maintain the physician’s 

original written order or prescription in their files. The order or prescription must 

include: 

# the beneficiary’s name and full address; 

# the physician’s 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 physician’s 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 nonphysician 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 

Ordering Medicare Equipment 29 OEI-02-07-00080 
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 

completed by the supplier. 

# Section D is the treating physician’s 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 patient’s treating physician and the information regarding the 

physician’s 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 physician’s signature; and 

# the information in section B relating to medical necessity is true, accurate, and 

complete to the best of the physician’s knowledge. 

IMPROPER PHYSICIAN CERTIFICATIONS FOSTER FRAUD 

nscrupulous suppliers and providers may steer physicians into signing or authorizing Uimproper 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 physician’s 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 antikickback 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 

Ordering Medicare Equipment 30 OEI-02-07-00080 
equipment and supplies: 

# 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 

physician is not personally liable for erroneous claims due to mistakes, Ainadvertence, 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. 

Ordering Medicare Equipment 31 OEI-02-07-00080 
Physicians may violate these laws when, for example: 

# they sign a certification as a “courtesy” to a patient, service provider, or DME 

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 

Ordering Medicare Equipment 32 OEI-02-07-00080 
IN, OH, IA, MO

Ordering Medicare Equipment 33 OEI-02-07-00080 
Dallas TX, NM, OK, AR, 

LA, CO, UT, WY, 

MT, ND, SD, NE, KS 

214-767-8406 

Los Angeles AZ, NV, So. CA 714-246-8302 

San Francisco No. CA, AK, HI 415-437-7961 

OR, ID, WA 

Ordering Medicare Equipment 34 OEI-02-07-00080 
APPENDIX E 

Comments on the Draft Report

We received comments from the draft report from HCFA. They concur with our 

recommendations. 

Ordering Medicare Equipment 35 OEI-02-07-00080 
Ordering Medicare Equipment 36 OEI-02-07-00080 
Ordering Medicare Equipment 37 OEI-02-07-00080 
Ordering Medicare Equipment 38 OEI-02-07-00080