By Lisa Elswick, Bernard Ford, and Kristina Kahan
On Feb. 15, 2018, the Office of Inspector General (OIG) released its report, Wisconsin Physicians Service Paid Providers for Hyperbaric Oxygen Therapy Services that Did Not Comply with Medicare Requirements. The report details a troubling overall 85% error rate principally relating to medically unnecessary hyperbaric oxygen therapy (HBO) services1 rendered to Medicare beneficiaries in the Wisconsin Physicians Services (WPS) Government Health Medicare Administration Contactor (MAC) Jurisdiction 5 (J5).2
The OIG noted there are 208 providers remaining within the WPS jurisdiction that have not been reviewed and which have received potential overpayments estimated at $42.3 million. Consistent with the OIG’s recommendation, WPS is in the process of putting these providers on notice of their obligation to investigate and return identified overpayments for HBO services within a 6-year time frame, consistent with the 60-day rule.
Providers in the WPS jurisdiction would be best-served to evaluate their HBO services for compliance with the Centers for Medicare & Medicaid Services (CMS’) requirements. If issues are identified, providers should follow the self-disclosure protocol in their continued review. HBO is a unique service line, and attention should be paid to soliciting involvement from qualified industry wound care/HBO experts in their review of documentation, including the sampling methodology. Bear in mind, a selected sample should be representative of the volume of services rendered during a 6-year time frame.
Recognizing there are many providers that have a wound management company overseeing their HBO programs, and in light of the 2015 qui tam3 litigation with the largest wound management company in the United States, reviews for HBO should be conducted under privilege and independent of HBO center staff or management company staff involvement. This will minimize bias in conducting the review and safeguard objectivity in review of the documentation and applying the relevant CMS coverage guidelines.
HBO is primarily rendered in a hospital outpatient department setting with trained technicians and nurses, and overseen by HBO-trained providers. According to CMS, HBO is indicated for 15 covered conditions, each with specific documentation requirements. Providers are responsible for knowing and adhering to CMS’ HBO National Coverage Determination Policy (NCD 20.29) in addition to their respective Medicare Administrative Contractor (MAC) HBO Local Coverage Determination (LCD) policy and/or HBO Article. It is simply unacceptable to merely get the Healthcare Common Procedure Coding System/Current Procedural Terminology code and ICD-10 diagnosis code “right.” Providers must exercise diligence in ensuring that all documentation requirements, limitations, and utilization guidelines detailed in the coverage policy are met.
CMS’ and the OIG’s apprehensions with overutilization of HBO services has been ongoing for many years.4 On Feb. 28, 2018, CMS ended its three-year HBO prior authorization demonstration for Illinois, Michigan, and New Jersey. The results will likely determine CMS’ path forward for ensuring Medicare beneficiaries receive medically necessary HBO services. In the interim, some MACs, such as Novitas Solutions, Medicare MAC Jurisdiction L (JL)5 have introduced Targeted Probe and Educate (TPE)6 reviews for HBO and the OIG7 will continue to focus its efforts on combating inappropriate HBO utilization. The OIG also confirmed it is performing review of payments for HBO services made by another MAC.
Now is the time for providers who perform and bill for HBO services in every Medicare jurisdiction, whether under review for HBO or not, to initiate proactive reviews of HBO services. Additionally, prior to treating a patient with HBO, providers should implement a comprehensive process to ensure medical necessity and all documentation requirements dictated by CMS, NCDs, and/or LCDs or Articles are included in the medical record.
1 Two of the 120 (2%) sampled claim errors were identified as billing errors; 100 of the 120 (83%) sampled claim errors were medically unnecessary services.
2 WPS J5 MAC includes Iowa, Kansas, Missouri, and Nebraska, and Part A National Providers.
3 United States vs Healogics.
4 Health and Human Services Office of Inspector General, Hyperbaric Oxygen Therapy. Its Use and Appropriateness. October 2000.
5 Novitas Solutions Medicare MAC JL includes Delaware, Maryland, New Jersey, Pennsylvania and the District of Columbia.
6 Centers for Medicare and Medicaid Services Medical Review and Education-Targeted Probe and Educate includes three rounds of prepayment probe reviews with education. Providers are selected based on the MAC’s data analysis.
7 The OIG 2018 Work Plan includes HBO Services – Provider Reimbursement in Compliance with Federal Regulations.