Straight Talk Tuesday

HBOTThere is a lot going on about hyperbaric oxygen therapy documentation.  The start of the prior authorization demonstration program for non-emergent hyperbaric oxygen therapy was delayed a bit but is it now active in Illinois, Michigan, and New Jersey.  If prior authorization is not sought for a Medicare beneficiary, claims will be on a 100% post-payment review.  The conditions that will be available for prior authorization include preparation and preservation of compromised skin grafts, chronic refractory osteomyelitis, osteoradionecrosis, actinomycosis, and DFUs.  I am going to predict 2 things: (1) the pre-authorization trial program will result in a dramatic reduction in HBOT services in those regions, and (2) within 3 years, prior authorization for non-emergent hyperbaric oxygen therapy will be a national requirement.  The word on the street is that there has been about a 50% denial rate for the charts that have been submitted – some of them for having an illegible signature.  However, I am hearing some worrisome things, like a denial of a patient with late effects of radiation because they didn’t have a Wagner grade documented.  The radiation injury was to the head and neck and the patient incidentally had diabetes.  If you are in the pre-authorization region and you have experiences like this, the UHMS Committee on Quality, Utilization, Authorization, Reimbursement and Coverage (QUARC) would like to hear from you so we can better understand what is and is not working in these regions (in other words, email me).