Guest Post by Dr. Helen Gelly: Big (Bad) News for HBOT Providers in the WPS J5 Jurisdiction

In February 2018, the Office of Inspector General (OIG) released a report entitled “WISCONSIN PHYSICIANS SERVICE PAID PROVIDERS FOR HYPERBARIC OXYGEN THERAPY SERVICES THAT DID NOT COMPLY WITH MEDICARE REQUIREMENTS.”

  • The OIG evaluated the region under the jurisdiction of WPS J5 (Iowa, Kansa, Missouri, Nebraska, and all legacy hospitals) for 2013-2014.
  • In an audit of 120 claims, only 18 were found to be compliant, an error rate of 85%.
    • OIG estimated overpayments for HBOT were $300,789.
  • Extrapolated to the entire J5 region, the OIG estimated that WPS J5 providers were overpaid by $42.4 million during the audit period 2013-2014.

What does this mean?

  • The OIG has recommended that WPS notify ALL OF THE HOSPITALS that provided hyperbaric oxygen therapy services in hospital based outpatient departments in WPS J5 to begin SELF-AUDITING and returning overpayments.
  • WPS has begun to send letters to this effect, the first of which have been received by hospitals.
  • Hospitals are being asked to determine if overpayments exist within a 6 year look back period.
  • HBOT facilities should be aware that it is possible a similar audit and recovery process of HBOT payments  will expand to other Medicare jurisdictions.

What are the hospitals in WPS J5 supposed to do?

Background: How did we get to this point?

  • The First OIG Report: Almost 2 decades ago, the OIG came out with the first evaluation of “HYPERBARIC OXYGEN THERAPY Its Use and Appropriateness.”
    • OIG reviewed claims between 1995-1998.
    • A panel of four physician experts in hyperbaric medicine reviewed all of these claims using an audit tool that had been created by the OIG.  The scope was national.
    • Report found that 22.4% of all HBOT payments were for non-covered indications, 9.2% represented inappropriately paid claims due to inadequate documentation, 11% were deemed to be excessive, and 74%  of the claims did not have evidence of physician attendance.
    • Despite the fact that this report came out in 2000, nothing was implemented by CMS.
  • The Orange Book: In 2005, the Orange Book was released
    • The Orange Book summarized over 90 unimplemented recommendations of the OIG.
    • Included were recommendations for HBOT they noted that over $19.1 million had been paid for inappropriate or excessive treatments, and that an additional $11.1 million had been paid for treatments of questionable quality.
    • Together, over $30.2 million were thought to have been inappropriately out of a total payment of $49.9 million dollars.
    • That translates into a 61% error rate.
  • Edits to C1300:
    • In 2005, CMS response by putting in some “edits” for hospital outpatient departments (HOPD) billing C1300 (now G0277)
  • HBOT Prior Authorization:
  • Targeted reviews by WPS:
    • Although Prior authorization program has ended, in 2017 it spawned a series of targeted reviews by WPS Government Health administrators and Palmetto GBA.
    • These claims audits had error rates from 60-100%.
  • The OIG Working their Plan

The OIG work plan for 2017 placed HOPDs providing hyperbaric oxygen therapy services as the #1 probe on their work plan list.