Reminder: Physicians must verify medical necessity before signing certification forms

posted 02.21.12

Physicians must verify medical necessity before they sign a certification form or statement that is presented by durable medical equipment suppliers or home-health agencies. Physicians must complete Section B of the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form, which documents medical necessity of the requested items. Completion of forms, such as those for claims and prior authorization, is considered an administrative cost and is not eligible for reimbursement by Texas Medicaid.

The following are examples of when physicians may have violated these laws.

• They sign a certification as a “courtesy” to a patient, service provider, or DME supplier without having 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.
• 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. A physician who signs a false or misleading certification through mistake, simple negligence, or inadvertence will not be considered personally liable. However, the physician may still be unwittingly facilitating the perpetration of fraud on Medicaid by suppliers or providers.

To avoid unwitting facilitation of fraud, all physicians should review and familiarize themselves with the information in the Special Fraud Alert for Physician Liability for Certifications in the Provision of Medical Equipment and Supplies and Home Health Services that is located on the Office of the Inspector General website at http://oig.hhs.gov/fraud/docs/alertsandbulletins/dme.htm.

Retrospective review

Retrospective review may be performed to ensure that the documentation in the client’s medical record supports the medical necessity of requested services.

The date last seen by the physician must be within the past 12 months unless a physician waiver is obtained. The physician’s signature on the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form is valid for only 90 days before the initiation of services. The requesting provider may be asked for additional information to clarify or complete the request.

To facilitate a determination of medical necessity and avoid unnecessary denials when requesting prior authorization, physicians must provide correct and complete information that supports the medical necessity of the requested equipment or supplies, which includes the following.

• Accurate diagnostic information pertaining to the underlying diagnosis or condition as well as any other medical diagnoses or conditions, including the client’s overall health status.
• Diagnosis or condition that causes the impairment, which results in a need for the requested equipment or supplies.

The toll-free number for the TMHP Home Health Services Prior Authorization Department is (800) 925-8957.

Providers may also refer to section 2.2.2, “Durable Medical Equipment (DME) and Supplies” in the 2011 “Texas Medicaid Provider Procedures Manual, Durable medical Equipment, Medical Supplies, and Nutritional Products Handbook” for more information about DME.