It’s clear that successfully fighting fraud engineered by sophisticated criminal organizations requires a number of concurrent industry strategies — including enlisting the latest technology.
“When fraud and abuse come into focus, it is often addressed through tighter policies and increased documentation requirements,” said Robin Randolph, senior vice president of sales and marketing for sovaSage Inc. “While necessary, this approach has also created a system that relies heavily on manual processes, fragmented data and retrospective validation.”
Government programs, Randolph added, “have continued to tighten reimbursement policies and reinforce requirements around patient qualification, usage and documentation. While these efforts are designed to protect the system, they also place growing pressure on DME suppliers and physicians, who must navigate increasingly complex and time-intensive compliance expectations.”
And of course, the ripple effects also reach patients. “In some cases, these requirements can unintentionally create barriers to care,” Randolph said. “Patients who would benefit from therapy may face delays or additional hurdles, while providers are challenged to balance compliance demands with timely access to treatment.
“Nowhere is this more evident than in PAP [positive airway pressure] therapy.”
Keeping up with adherence data
Medicare guidelines, Randolph noted, require patients to “meet strict adherence criteria within the first 90 days to maintain coverage. That means demonstrating consistent usage, typically at least four hours per night on 70% of nights, supported by objective device data and physician follow-up. These requirements are clear, but the way they are managed operationally is often not.”
Many suppliers, she added, still rely on manual workflows, including logging into multiple manufacturer platforms, pulling usage reports intermittently, documenting compliance after the fact, and attempting to reconcile patient activity with billing and resupply schedules.
“This introduces risk,” Randolph said. “Manual processes increase the likelihood of human error, missed interventions and incomplete documentation. More importantly, they create gaps in visibility at the exact time when early intervention matters most. In some cases, organizations attempt to address this by outsourcing patient management and resupply functions to third-party partners who act as extensions of the DME provider. While this can help expand operational capacity, it does not inherently reduce compliance risk.
“Shifting the work does not eliminate the risk. It simply relocates it. The question then becomes: how do we turn this moment into an opportunity for the industry?”
AI enters the conversation
“Rather than continuing to layer on manual processes and administrative burden, there is an opportunity to rethink how compliance is achieved altogether,” Randolph said. “Continuous monitoring creates the transparency, consistency and accountability that regulators expect, without adding friction to care delivery. This is where technology, particularly AI [artificial intelligence], has the potential to shift the conversation.”
She noted that AI “allows providers to move from episodic, retrospective documentation to continuous, real-time visibility across the patient journey. Usage, treatment parameters, and adherence thresholds can be captured automatically, without requiring constant manual review or even direct patient outreach to verify activity.”
While AI is a buzzword that can evoke vague futuristic images, Randolph explained that AI adopted by HME businesses today can enable organizations to measure real usage patterns in real time, identify patients who are trending toward noncompliance, intervene earlier with specially targeted support, and maintain a consistent, time-stamped record of therapy and engagement.
“The impact becomes even more significant when considering resupply and ongoing medical necessity,” she added. “Many payers, including Medicare, require documentation that a patient continues to use PAP therapy in order to justify resupply of masks and accessories. However, in a manual environment, resupply workflows can become disconnected from actual patient usage.”
The results can raise compliance and fraud risk by “supplying equipment without documented continued use, billing for items that may not meet medical necessity requirements, lacking sufficient records to defend claims in an audit,” Randolph said. “AI helps close that gap.”
How AI aligns resupply decisions with usage and clinical need
Incorporating AI into a resupply program can ensure “that every supply delivered is supported by objective data and appropriate documentation,” Randolph noted. “At the same time, AI introduces a dual benefit that extends beyond compliance. First, it improves patient outcomes by enabling earlier and more consistent intervention, increasing the likelihood that patients meet and maintain adherence. Second, it fundamentally shifts productivity across the organization. Instead of teams spending time logging into multiple systems, pulling reports and manually documenting activity, that effort is redirected toward higher-value work such as patient support, intervention and care coordination.”
She added that these improvements are “especially important in an environment where providers are being asked to meet higher compliance standards without proportionally increasing staff. It allows existing teams across compliance, billing and operations to function more effectively, with clearer visibility and stronger alignment between clinical activity and documentation.”
AI can also offer “meaningful protection,” Randolph said, for physicians and referral partners. “Advanced reporting can clearly demonstrate days used and hours used; therapy thresholds met; changes in treatment over time; ongoing justification for prescriptions and resupply; number of times a patient engages with support tools; number of proactive and reactive patient outreach interactions; documented live coaching interventions, including reason and outcome; [and] reporting segmented by payer, physician, location and individual therapist.”
Ultimately, suppliers who shift to AI move “from a system that asks providers to prove what happened after the fact, to one that documents the patient journey as it happens,” Randolph said. “That is where the real opportunity lies.”
Editor’s note: This story was originally published in the June 2026 digital edition of HME Business. Register to view the read the entire issue.
