In the upcoming November edition of Today’s Wound Clinic, Helen Gelly, MD has written a very informative “Educational Note to Provider.” Helen, and Joe Darrah, the Managing Editor of TWC have graciously allowed me to share this
The prior authorization (PA) project for hyperbaric oxygen therapy that was started by the Centers for Medicare and Medicaid (CMS) has been implemented fully, and all states, New Jersey, Michigan and Illinois are currently participating. The result has been a reduction in utilization that has been substantial. Reports vary from 40%- 80 % rate of denials, representing a significant reduction in hyperbaric oxygen treatments. It is not surprising to note that the prior authorization states number amongst the eleven states with the highest number of fraud and error-prone providers (Florida, California, Michigan, Missouri, North Carolina, Ohio, Pennsylvania, Texas, New York, Louisiana and Illinois).
CMS has had considerable experience in using prior authorization projects to curb perceived over utilization and potential fraud and abuse. By their very nature, prior authorization projects are limited in geographic scope. They can be expanded, but a national implementation requires some level of congressional intervention, and this is challenging in today’s political environment. However, traditional methods of auditing payment can be used instead; both prepayment and post payment review. 
Post payment review and takebacks have taken a number of forms; this topic has been comprehensively covered in Today’s wound clinic October 2015 issue in an article written by Valerie Larson-Lohr, MSN, APRN.
Pre-payment review allows Medicare to review claims before payment for a service that has already been rendered in order to reduce their Comprehensive Error Rate Testing (CERT) error rates. The implementation of a pre-payment audit is well within the scope of all Medicare intermediaries, and present challenges to both physicians and hospitals. Noridian, the intermediary that covers California, has recently implemented a “Probe and Provider on Review” (POR) for hyperbaric oxygen therapy provided in an outpatient hospital department. Although this is limited to OPHD now, the “creep” to physician payment is unknown. In the PA projects, if the hospital does not receive prior approval, the physician payment is also affected.
What does that mean to both a provider and an outpatient hospital department? The steps involved have many parallels. The reasons for flagging a provider are varied, but may include billing for a service that has been identified as “at risk” for fraud and abuse and over utilization. Hyperbaric therapy has unfortunately acquired that designation. Initial screening of claims is done using the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs). NCCI Edits identify improper coding, MUEs limit the number of units of service within a day that would be seen as medically necessary. For example, the MUE for 99183 (physician supervision of HBOT) is 1, the MUE for G0277 (30 minute segment of HBOT) is currently 5. Patients treated on a BID schedule would be automatically flagged as “unlikely” and require Medical Review (MR).
A recent educational session offered by Noridian identified the steps that part of the HBO probe review. Providers will be notified by letter of the prepayment review, and an Additional Documentation Request (ADR) will be sent to the provider. The provider must respond within 45 days, and if no response is received; the denial is made for non-receipt of medical records. If the claim is denied (or if you are dissatisfied with the determination), then a redetermination must be sent within 120 days. The MAC redetermination review process has 60 days to respond. If you are not satisfied with the outcome, you have 180 days to file a reconsideration request with the Qualified Independent Contractor (QIC) that is working with your MAC. At this level ALL the supporting documentation that you foresee using in your defense must be submitted, including literature, position statements and the complete but relevant medical record. The QIC has 60 days to respond, if unfavorable, you may go to the third level of appeal, which is the Administrative Law Judge. At this level, you cannot easily submit additional information. Ultimately, you have five levels of appeal.
Common reasons for unfavorable decisions for hyperbaric therapy include the lack of a legibly signed physician order for the hyperbaric therapy that must include the delineation of treatment pressure, rate of descent/ascent/ air breaks, planned duration of therapy, and frequency per day. Blood sugars must be ordered. The treatment note must clearly show the length of time of the total hyperbaric treatment, the appropriate treatment diagnosis, documentation that the physician was available and present during the therapy, and must be signed. Legibly. The initial ADR must have supporting documentation sent along with the treatment record, which would include the initial evaluation that addresses the documentation of conventional care, lack of response, and goals for the hyperbaric therapy.
However, having all of that documentation is not necessarily a formula for immediate success. There is considerable variability in the quality of the reviewers, and depending on the medical director and the interpretation of the NCD, LCD or Article, the review process can be arduous. Having had the dubious distinction of being under pre-payment review for the better part of 2015, I have more than my fair share of stories to share. Some make me want to tear my hair out, others are so ludicrous that laughing is the only way to maintain sanity. These comments are taken verbatim from the responses to redeterminations; the responses are my editorial comments.
“The provider is billing G0277 x4. According to the national Coverage Determination (NCD) for HYPERBARIC Oxygen Therapy (20.29), treatments greater than two services per day must have documentation supporting medical necessity for increased frequency…The claim is paid for two treatments.”
Perhaps the medical reviewer was looking at the MUE for 99183 and not G0277? In any event, nowhere in the NCD does it reference frequency of treatment.
“There is no a Wagner grade III classification or higher. The documentation only verifies one service according to National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29). The use of HBO therapy is covered as an adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. The documentation fails to support the service. Therefore, the denial is upheld.”
Well, it is pretty hard to have a Wagner grade III ulcer when the patient has radiation cystitis…however they had a co-morbidity of diabetes, and the DFU requirements are transposed to delayed effects of radiation. But it gets better.
“This 69 year old female with soft tissue necrosis and history of radiation received one dive..and was billed and paid with service 99183.. Educational note to provider: There is no recorded Wagner scale of wound on the HBO document as required per National Coverage Determination (Publication 100-03), Chapter 1, Part 1, Section 20.29 Hyperbaric Oxygen Therapy.”
Educational note to reviewer: There is no Wagner scale of the wound in osteoradionecrosis of the mandible. Wagner refers to the ulcers of a dysvascular, neuropathic diabetic foot, and only the foot. However, the tendency for the requirements of the DFU to be reflected in all diagnoses is evident.
“70 ( seventy) year old female patient performed on …Our Medical review staff states that after review of the submitted documentation, it is determined that the documentation does not support the medical necessity..the use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least thirty days of treatment with standard wound therapy and must be used in addition to standard wound care…the documentation reflects this is a patient with a left nasal flap. However, the documentation only supports that this wound has been present for eight (8) days. Therefore the denial is upheld”
The indication for compromised flap/graft is urgent, and does not qualify for 30 days of standard wound care…but here again, is the tendency is to paint all indications with the DFU brush.
It is inevitable that there be some confusion at the beginning of the implementation of a process. These examples are more a reflection of the perception that every hyperbaric indication requires 30 days of standard care, and that the Wagner grading system for diabetic foot ulcers can be applied to any and every part of the body.
The hyperbaric community needs to pay attention to what is being documented in the denials in the Prior Authorization project as well as the Noridian POR. We need to share this information with each other, using blogs (http://www.todayswoundclinic.com/blogs) to make certain that the standards that we are judged by are accurate and that we are following trends in misinformation, so that they may be corrected. Just an “Educational note to provider.”
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Dr. Gelly has been involved in hyperbaric medicine and wound care since 1991. Past positions have included Medical Directorships at academic and community hyperbaric medicine and wound care programs. She started a non-hospital affiliated hyperbaric medicine center which was one of the first UHMS accreditated centers. She has been actively involved in billing and reimbursement issues for both facilities and physicians. Until recently, she was the Medical Director of Hyperbaric Physicians of Georgia, a group of physicians dedicated to the practice of hyperbaric medicine and wound healing, with 5 subspecialty boarded physicians in its membership. In addition to lecturing nationally on hyperbaric medicine and wound healing for many years, she was the president of the Gulf Coast Chapter of the UHMS from 2005-2007. Currently, she serves as the Emeritus Medical Director of Hyperbaric Physicians of Georgia, and as C.E.O. for HyperbaRXs.
Caroline Fife, MD
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The dedication for quality care and outcomes continues to be a concern for health care around the country . I have been involved with hyperbaric therapy for 26 years; what distrubs me is the lack of evidence based literature and research that we have beg for, for years supporting what we do and supporting the length of every treatment completed. I feel we have pushed our own demise by not justifying why we give airbreaks without the evidence to back a 90 min treatments (total time in chamber) have always been our practice and we have great outcomes. There is no evidence supporting keeping patients in the chamber 16 t minutes longer improves outcomes. Greed by providers in many aspects of health care have hurt not only hyperbaric but health care. At the same time when I look at the patients that we have helped I’m proud of my profession. We have always steered on the conservative side of our patient selection and make sure our documentation is precise and accurate.
Regarding the 11/20/15 blogpost: Gelly wrote the following paragraph and I’m confused as to whether this is the procedure in the prior auth program that’s going on in MI, NJ, IL or if this is related to something else. The reason why I’m confused is because when I read the Federal Register notice about the program, it looks like once you submit your documentation, you get a response w/in 10 days. What’s described below sounds like a process that is a lot longer than 10 days and even though the program is for non-emergent uses, waiting any period of time that resembles the timeline below seems awfully long. I don’t know how long these wounds can last w/o treatment, so maybe this is fine and w/in typical time frame for you, but I think I’m a bit lost on what’s discussed below:
This is such a good question because it is confusing! Prepayment review is different from prior authorization.
First, let’s review what prior authorization is. Under prior authorization, which is active in only 3 states (MI, IL, NJ) , BEFORE to rendering the hyperbaric service, you are required to send in your records and the MAC has 10 days to make a determination as to whether HBOT is medically indicated and will be covered for the indication requested.
Noridian has initiated Pre-payment review in at least some of the states in its jurisdiction. In this scenario, you have provided the hyperbaric service and have sent in the claim for payment. However, before the MAC pays the claim you have submitted, Noridian requests medical records as part of a “prepayment review.” These records are reviewed in their “Medical Review” department and they have an unlimited amount of time to review the records before deciding whether they will pay you for the services that you have already provided. However, this review usually is completed within 30 to 45 days. If your claim is denied for lack of medical necessity, you may ask for a “redetermination.”
Redetermination is theoretically performed by an independent group, but they utilize the same guidance materials when they review records. This process takes about 60 working days. If denied at the redetermination stage, you may request “reconsideration.”
Reconsideration is supposed to be an independent audit. This process takes another 60 days. Please note that by this time, the bill you have submitted for the services you have ALREADY PROVIDED TO THE PATIENT, has now gone unpaid for at least 5 months. The next step is to request a hearing before an administrative law judge. How long it takes for this to happen depends on how busy the docket is, so it can take weeks or months before your case is heard. If denied before the judge, you then have the option of going to court.
While “prior-authorization” requires Congressional involvement in order to be expanded, the pre-payment review process in which you render HBOT services but then may wait many months to be paid -if EVER, can be initiated by the MAC at any time. It appears that this process has begun with Noridian but is expanding to other carriers.
It is important for hyperbaric providers to watch for the requests for records that are part of prepayment review. If these requests are sent directly to the hospital medical records department and languish there, after 45 days the claim is simply denied for lack of responsiveness.
The prepayment review process could actually be a far greater threat to the future of hyperbaric medicine because claims for services already rendered could go unpaid for 6 months or longer as they work through this process (not to mention the cost of shepherding claims through these steps). This delay in payment could spell financial disaster for a hyperbaric operation.