In a rare move, the Centers for Medicare & Medicaid Services (“CMS”) terminated the payment suspension (the “Suspension”) it previously imposed on a durable medical equipment (“DME”) supplier and agreed to release withheld funds to that provider as a result of Mandelbaum Barrett’s healthcare team’s appeal to CMS.
According to CMS, the Suspension was allegedly based on “credible allegations of fraud,” including information that the supplier billed Medicare for DME that was medically unnecessary and delivered to beneficiaries despite their declining the same and under circumstances where the beneficiaries had no knowledge of or prior relationship/consultation with the ordering provider. CMS supported its allegation with references to interviews with the relevant beneficiaries.
To disprove CMS’s allegation and demonstrate the propriety of the supplier’s conduct, our team produced documentation proving that the supplier dispensed the DME based on valid provider orders and letters of medical necessity for which CMS received a claim from the ordering provider, as well as audio recordings of the supplier’s discussion with the beneficiaries in which they confirmed their desire to receive the DME. We also posited that DME suppliers do not and are not legally authorized to determine or verify the medical necessity of DME and are entitled to rely on the ordering provider’s order in that regard.
Given the sheer size of Medicare as a payor for DMEPOS, this result prevented the financial demise of our client and preserving its ability to continue serving its community.