Medicare Compliance & Reimbursement

Question: My billing supervisor erased data that the doctor wrote on a certificate of medical necessity (CMN) for some durable medical equipment (DME) and replaced it with something else before the paperwork was submitted to Medicare. I even had a previous supervisor say that was an OK practice and not a big deal. Is this fraudulent?

Minnesota Subscriber

Answer: Yes, if a CMN is altered by anyone who is not the physician who wrote it, it may be fraud.

“If there is a change made to any section of the CMN after the physician has signed the CMN, the physician must line through the error, initial and date the correction; or the supplier may choose to have the physician complete a new CMN,” the Centers for Medicare & Medicaid Services (CMS) expounds in Chapter 5 of the Medicare Program Integrity Manual.

Plus: It could cause problems for the DME company as well, particularly if they’re audited.

“In the event of a post pay audit, the supplier must be able to produce the CMN or DIF and, if requested by the DME MACs or UPICs DME, produce information to substantiate the information on the CMN or DIF. If the supplier cannot produce this information, the DME MACs and UPICs should deny the service and initiate the appropriate administrative or corrective actions,” the manual says.

Bottom line: Adjusting a CMN if you’re not the physician who wrote it doesn’t comply with Medicare’s (and most other payers’) rules.