The routine waiver of government health care beneficiaries’ copayment amounts is Durable Medical Equipment fraud. Medicare Part B only cover 80% of the cost of DME supplies. The patient must pay the remaining 20%. If a DME supplier bills Medicare for the 80% but knowingly waives the patients 20% copayment amount, they may have violated the civil False Claims Act and the federal Anti-Kickback Statute.

Routinely waiving DME patient copayment amounts violates the federal False Claims Act because the DME supplier is misstating its actual charge. This is because Medicare Part B only covers 80% of DME supplies. So, for example, if the DME supplier claims that its charge for a piece of DME equipment is $100 but routinely waives the copayment, the actual charge is $80. As a result, Medicare should be paying 80% of $80 ($64) rather than 80% of $100. Therefore, in this example, Medicare paid $16 more than it should have for the DME item.

Routine waivers of DME copayment amounts may also violate the federal Anti-Kickback Statute. The federal Anti-Kickback Statute makes it illegal to offer, pay, solicit or receive anything of value as an inducement to generate business payable by Medicare or Medicaid. When suppliers forgive financial obligations for reasons other than financial hardship, they may be unlawfully inducing that patient to purchase items or services from them.

Indeed, it might seem a little odd that the federal government would require Medicare beneficiaries to pay their copayment amounts, and punish DME suppliers who waive such amounts. However, it makes sense. In 1994, the U.S. Office of Inspector General released a special fraud alert on Routine Waiver of copayments or deductibles under Medicare Part B. In this fraud alert, the OIG stated that:

At first glance, it may appear that routine waiver of copayments and deductibles helps Medicare beneficiaries. By waiving Medicare copayments and deductibles, the provider of services may claim that the beneficiary incurs no costs. In fact, this is not true. Studies have shown that if patients are required to pay even a small portion of their care, they will be better health care consumers, and select items or services because they are medically needed, rather than simply because they are free. Ultimately, if Medicare pays more for an item or service than it should, or if it pays for unnecessary items or services, there are less Medicare funds available to pay for truly needed services.”

No Fees Without Recovery

Ross M. Wolfe and the Weiser Law Firm litigate whistleblower lawsuits on a contingent fee basis, so whistleblowers do not pay attorneys’ fees or court costs unless there is a recovery.

Please contact Ross M. Wolfe if you would like to speak with a whistleblower attorney for more information about the whistleblower process, Durable Medical Equipment Fraud, routine waivers of Medicare copayment amounts or to schedule a confidential free consultation to discuss your potential case.