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.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
