Americare: Off-the-Shelf Inserts Billed as Custom-Molded

In the Americare diabetic inserts fraud case, prosecutors charged that the company billed Medicare for three pairs of custom-molded inserts per patient while supplying off-the-shelf inserts. The Justice Department’s February 2011 guilty-plea announcement reports that the company’s owner and customer-service director admitted billing Medicare for equipment and supplies never provided. The allegation put patients and taxpayers on the losing side of the same sale: stock inserts for the patient, custom-insert claims for Medicare.

From a Free-Shoe Offer to a Custom-Insert Claim

The criminal indictment described a sales operation that offered Medicare beneficiaries diabetic shoes and inserts every year, including when the supplies were not medically necessary. In its December 2009 charging announcement, the Justice Department identified the business as Americare In Home LLC and described the offer as “free.” The company operated in the Brooklyn area.

The indictment alleged that the owner and customer-service director solicited beneficiaries, and that the owner and others measured their feet with a measuring stick or ruler. Prosecutors charged that the owner and customer-service director then submitted, or caused others to submit, the false custom-insert claims.

A foot measurement gave the transaction an appearance of individual attention. Prosecutors alleged that Medicare received a claim describing a custom-molded product, while the patient received a stock insert.

In their guilty pleas, announced on February 10, 2011, both operators admitted billing for equipment and supplies that Medicare beneficiaries never actually received.

What Medicare Was Supposed to Be Buying

The coverage conditions described in the criminal charging announcement tied diabetic footwear to the patient’s medical need. The treating physician had to determine medical necessity, certify that the patient had diabetes and treat the patient under a comprehensive diabetes-care plan. The patient also needed a specified foot condition, such as an ulcer, deformity or poor circulation.

The announcement described an annual allowance of up to one pair of diabetic shoes and three pairs of inserts. In that 2009 account, Medicare covered heat-molded and pressure-molded inserts, but did not reimburse inserts that were not custom molded.

The alleged conduct crossed both the medical-need and product boundaries. The sales offer reached people who allegedly did not need the supplies. The subsequent claims described inserts different from those furnished.

Dia-Foot and the Later Custom-Insert Allegations

Dia-Foot‘s settlement resolved allegations about the same product representation at issue in Americare’s case: inserts sold as custom even though they did not meet Medicare’s custom-fabrication standards.

The people who order, supply or fit the inserts can explain whether the physical product matches it.

Oxygen Plus and the Fitting Certifications

Where Americare’s indictment concerned the product billed, the whistleblower complaint against Oxygen Plus alleged that false fitting certifications concealed failures to fit diabetic shoes and inserts properly.

What Evidence Is Needed for Reporting Fraud?

For diabetic insert billing, useful evidence connects what was prescribed, how the insert was made and fitted, what the patient received and what Medicare was billed for. We look at those connections with the person who knows the business, including what the supplier’s staff understood about the product they were selling.

In a case like Americare’s, we would compare purchase and product records with the custom-insert descriptions used in billing. For a fitting allegation like the one in the Oxygen Plus complaint, we would examine the certifications alongside who actually performed the fitting. An employee’s account of how those records came to differ can explain more than either document alone. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know Which Inserts Went Into the Shoes

If you saw stock inserts billed as custom work or fitting certifications signed for work nobody did, speak to one of our Whistleblower Experts about how the inserts were billed. We build your strongest whistleblower case around your knowledge of the products and the decisions behind the billing, bring in medical equipment fraud whistleblower lawyers, and stay beside you throughout the case.