Most hyperbaric oxygen therapy practitioners know about the first OIG (Office of Inspector General) audit of HBOT which happened in 1998 (published in 2000). I’ve blogged about this before because I was the (relatively young) President of the Undersea and Hyperbaric Medical Society (UHMS) and it was a traumatic experience for me. Little did I know that exactly 20 years later I would look back with fondness on our Y2K encounter with the OIG because at least back then, we were able to recommend to the OIG some of the most respected hyperbaric practitioners in the country to perform those chart reviews, and had some input on the review criteria. When that experience was over, I warned everyone that the OIG would be back and we needed to get our collective act together. However, no one enjoys being proven right when you tell children not to run with scissors. Twenty years later, the OIG is methodically reviewing the performance of each Medicare Administrative Carrier (MAC) when it comes to how they implement Medicare policies pertaining to HBOT. The OIG has just released a report on its review of the MAC First Coast Services Options, Inc. (First Coast), and the news is grim. Unlike in 1998, we don’t know who did the review or what specific criteria they used.
As you remember, from 2015 through 2018 CMS conducted a prior authorization demonstration program for non-emergent HBO therapy. One of the MACs involved in the HBOT prior authorization project was First Coast, which paid the second largest amount for HBOT outpatient therapy services in 2013 and 2014. In the just-issued report, the OIG states that its goal was to determine when the HBOT services paid for by First Coast complied with Medicare requirements. The review covered 46,857 outpatient claims totaling $44.3 million for CMS Jurisdiction N that contained HBOT services provided to Medicare beneficiaries during calendar years 2012 through 2015. The OIG selected a statistical sample of 120 HBOT claims submitted by 48 providers. We don’t know who these providers were; they were presumably selected at random based on the statistical sample. These 120 outpatient HBOT claims totaled $415,513 in billed charges. The OIG report states that First Coast made payments for HBOT in accordance with Medicare requirements for only 5 out of 120 claims.
The OIG has concluded that 92% of the HBOT charges paid by First Coast were paid improperly. Using this math, CMS overpaid for HBOT by $351,970. When the OIG extrapolated this improper payment rate to the total HBOT payments made, they estimated that First Coast overpaid providers in Jurisdiction N by $39.7 million for HBOT services. If the story could get worse, the reports states that the reason they did not review the remaining 5 claims was because a Recovery Audit Contractor (RAC) indicated that those were under review by another entity.
Although the report lists the Medicare criteria for non-emergent HBOT and states that these criteria weren’t met according to their review, it does not provide sufficient detail to understand exactly why (e.g. failure to document off-loading at each visit for 4 weeks? Were the DFUs interpreted as having “improved” during the 4 weeks of conservative care, and if so, how?). We have a lot of questions. We want to ensure that HBOT is used properly, but we worry about capricious interpretations of the rules and that the reviewers’ interpretation of the criteria can vary a lot.
The OIG made the following recommendations to First Coast. First Coast apparently concurred with the fist 3 recommendations and partially agreed with the last one.:
- Recover the portion of the $351,970 in Medicare over-payments.
- Notify the 70 providers responsible for the remaining 46,737 non-sampled claims with potential over-payments estimated at $39.3 million so that those providers can investigate and return any identified over-payments.
- Identify and recover any improper payments for HBO therapy services made after the audit period, and…
- Work with the Centers for Medicare & Medicaid Services to the extent possible in developing more effective automated HBO therapy prepayment edits in the claim processing system.
I’ve already proposed a way in which the quality measure structure could be harnessed to accomplish item #4, but right now the “just say no” approach is working better than actually trying to fix this problem. If there are any “deciders” out there who read blogs, you should know that there is an inexpensive, fast, fair, implementable method of accomplishing #4 that is EHR-agnostic and that’s already been pilot tested. But it looks like we are all just going to sit here and watch this patient bleed out, rather than trying to find the source of the hemorrhage and fix it. That’s going to be very, very messy.