Straight Talk Tuesday

Unless you are in one of the 3 states affected by the “preauthorization” requirement for hyperbaric oxygen therapy, you may not have been following this issue so let me fill you in. Medicare is rolling out a pilot project in which they are requiring non-emergency hyperbaric oxygen therapy to be pre-authorized in Illinois, Michigan, and New Jersey. The purpose of this project is to “test whether prior authorization helps reduce expenditures.” We have known this was coming since October of 2000 when the Office of the Inspector General (OIG) published its final report of an investigation into HBOT billing and determined that $19.1 out of $49.9 million (38%) of hospital and physician charges for HBOT were paid for inappropriate or excessive treatments. In a subsequent 2005 report, the OIG concluded that an additional $11.1 million in fraudulent hyperbaric charges resulted from confusion over or abuse of the current coverage policy, medical opinions that did not align with CMS guidelines, and inadequate documentation. The OIG pointed the finger of responsibility at the Medicare Administrative Contractors (MACs) for having failed to implement appropriate medical review standards, and recommended that CMS improve policy guidance (e.g., practice guidelines/physician attendance policy) and improve oversight by requiring the contractors to initiate consistent medical review procedures and deny payment in those cases for which HBOT is not a covered service.

So, the MACs are now doing just what the OIG told them to do even if it took them 10 years to do it. If you are wondering whether this increased oversight is really necessary, consider that the 2014 Margolis paper which questioned the effectiveness of HBOT in diabetic foot ulcers reported that 80% of the DFUs in the dataset were Wagner 2 lesions (Margolis, et al. Diabetes Care 2013 Feb 19, 2014). You can check my math but I think that means that only 20% of the DFUs included in the dataset from these centers met the first requirement of the Medicare National Coverage Determination (NCD) which is that a patient have a Wagner 3 lesion in order to qualify for HBOT. And if you think that this “pilot project” is going to be limited to 3 states, it’s time for you to retire. It will eventually be expanded to all jurisdictions. It pains me to recall that in October of 2000 when I was the outgoing UHMS president, I warned everyone this was coming if we did not get our house in order. What I will tell you now is that this issue is not the real threat to field of hyperbaric oxygen therapy since all it is really going to do is mandate detailed documentation to prove the patient meets the Medicare NCD criteria. The real threat to the future of HBOT I’ll tell you about next week (although I am sure no one is listening since they didn’t listen before).

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Prior-Authorization-Initiatives/Downloads/HyperbaricOxygenPriorAuthorization_ExternalFAQ.pdf

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