New Face-To-Face Exams Aim To End Medicare Fraud, But Not All in Louisville Think It’ll Work

Jean Lonergan has been a Medicare beneficiary since 1998.  She had knee surgery about a decade ago.  She’s also had back surgery and suffers from a spinal disease.

The 71-year-old Louisville resident said she is “fairly savvy” when it comes to dealing with salespeople—but a few weeks ago she invited a medical supplies salesman into her home.

When the salesman left, Lonergan was the new owner of a back brace she didn’t need.

“I knew the thing wasn’t going to work,” she said. 

For two weeks, she tried to return the brace.  She called and left messages, but only got “the run-around.”

A new requirement for Medicare beneficiaries and physicians  aims to prevent situations like Lonergan’s.

Starting this week, Medicare beneficiaries who need durable medical equipment—such as walkers, wheelchairs and oxygen tanks—are required to meet with physicians face-to-face before getting their prescriptions.

Keeping with requirements of the Affordable Care Act, the face-to-face exams must be conducted within six months before a new prescription for durable medical equipment is created.

According to the Centers for Medicare and Medicaid Services, a new prescription is needed when:

  • For all claims for purchases or initial rentals 
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If a local coverage determination (LCD) requires periodic prescription renewal (i.e., policy requires a new prescription on a scheduled or periodic basis)
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

The new rule is supposed to help stop fraud and put an end to medical supplies companies taking advantage of older patients, said Michelle List, social services program coordinator for Senior Medicare Patrol, a part of Louisville Metro Department of Public Health & Wellness.

List said Medicare loses about $60-$90 million a year to fraud.

Fraud commonly stems from medical supplies companies “harassing beneficiaries,” List said.

“The way we see it, typically, they’re calling them or sending faxes to doctors for approval for equipment,” she said.

But Lonergan said she doubts the new face-to-face requirement will do much to stop the fraud.

She said the fraud for durable medical equipment has “been an ongoing thing for a very long time.”

“Especially if you get some of the older people, it will be real easy to slip something in there they didn’t need and they will never know it,” Lonergan said.

Though the requirements for face-to-face exams are now in effect, the enforcement of the rule will begin later in the year, according to the Centers for Medicare and Medicaid Services.

Lonergan said she hopes the enforcement is strict, because rules like the new face-to-face requirement may encourage some doctors to team with medical supplies companies to boost sales of certain equipment.

“There could be people that go into the doctor’s office, not know much about the doctor, because they need a brace and it could all be set up,” she said. 

“I could see how they could set it up, it could be very easy, the (medical supply) company finds a few people a sends them to the doctor’s office, for money people will do the strangest of things.”

She said she sees accessibility as perhaps another downside to the new rule.  For Lonergan, getting to the doctor for the face-to-face exams will not be an issue because already makes visits a few times a month.

But for other people, she said, getting to a doctor can be a hassle.

“They’re not making it easy,” she said.

Here is a list of medical supplies that qualify as durable medical equipment:

  • Automatic External Defibrillators
  • Cervical Traction Devices
  • External Infusion Pumps
  • High-frequency Chest Wall Oscillation Devices
  • Home Glucose Monitors
  • Hospital Beds
  • Manual In-exsufflation Devices
  • Manual Wheelchairs
  • Nebulizers
  • Osteogenesis Stimulators
  • Oxygen
  • Patient Lifts
  • Pneumatic Compression Devices
  • Positive Airway Pressure Devices
  • Pressure Reducing Support Surfaces
  • Respiratory Assist Devices
  • Seat Lift Mechanisms
  • Speech Generating Devices
  • Transcutaneous Electrical Nerve Stimulators (TENS)
  • Wheelchair options and Accessories

Jacob Ryan

Jacob Ryan is the Urban Affairs reporter for WFPL.

@jacobhryan

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