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?
- The request is being made without guidance.
- The audit tool that the OIG used has not been made publicly available to the hospitals that are being asked to self-audit.
- WPS does not have a current article or local coverage decision (LCD) policy.
- The best guidance can be found in their Outpatient Hospital Services Edit (5HBOB) Hyperbaric Oxygen Therapy (HBO) Targeted Medical Review (TMR) for J5 Providers.
- J5A providers who receive one of these letters should request a copy of the audit tool that was used, so that they can use the same criteria when performing the self-audit.
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:
- In 2014, CMS started the Prior Authorization of Non-Emergent HBOT
- Non-affirmation rates were in the 50-80% range.
- 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.