My Christmas Wish List

Each patient I am currently treating with hyperbaric oxygen therapy (HBOT), plan to treat, or have recently treated is under some type of payment review, either by my Medicare Administrative Contractor (eg, prepayment review) or by a private insurance carrier (eg, prior authorization). I’ve been tracking the reasons for Medicare denial of HBOT with my colleague Helen B. Gelly, MD, FACCWS, UHM/ABPM, FUHM, and the growing list of reasons now includes that “the hyperbaric treatment note failed to specify that the patient was treated in a ‘hard-sided chamber.’”¹ Additionally, another colleague recently alerted me that she’s the subject of a Centers for Medicare & Medicaid Services’ (CMS’) Targeted Probe and Educate Medical Review Strategy for HBOT.² Each patient I’d like to treat with a cellular product requires prior authorization, and, frequently, Medicare Advantage plans are just saying “no.” Patients with high-deductible insurance plans are struggling to pay for wound dressing products, which are often not covered benefits, and it takes months to get the paperwork processed for diabetic shoes. There are many challenges and pitfalls to the success of operating your wound center. However, helping patients to get the important treatments and products they need to help their wounds heal, such as HBOT and diabetic offloading footwear, are just two of the most obvious examples. The threats I am more worried about are those that are not so obvious. For example, I just reviewed letters that two of my wound care colleagues received from Blue Cross^® Blue Shield^® regarding their “quality performance.” They are both internists and, like me, limit their practice to wound care and hyperbaric medicine. However, this private payer thinks they practice internal medicine. The payer decided whether to allow these wound care practitioners to remain in-network based on quality measure performance that the payer has calculated without any data submission on the part of the providers. The payer used a variety of claims-based internal medicine measures (eg, the use of statins among patients with high cholesterol) to decide whether wound care practitioners met current performance standards for internists. Thankfully, as a result of claims submitted by the patients’ other physicians (but credited to the wound care clinicians), my colleagues passed the payer’s quality assessment and can continue to see Blue Cross Blue Shield beneficiaries in our wound centers. I am not sure what would have happened had they failed, which would have been through no fault of their own.

Threats to reimbursement in wound care and hyperbaric medicine are increasing. It is likely that, due to lack of investment in HBOT research, reimbursement for more HBOT indications will be lost in 2018. The level of scrutiny applied to wound care and hyperbaric documentation is unprecedented. Treatment notes will need to be more detailed and meticulous than ever before. However, the most dangerous threats to the field are much less obvious. For example, how will wound care providers identify themselves as wound care clinicians without a specialty designation?³ How will we be able to use cellular and/or tissue-based products (CTPs) without outcome measures for them? How will we determine which products provide the most value (benefit for the cost) without reporting healing rates by risk classification? How will we get CMS and private payers to support the reporting of wound care-relevant quality measures? It’s true that I worry about day-to-day payment for services, given all the ongoing audits; however, I worry more about the long-term survival of our field. With that in mind, if you see Santa this year, please pass along my Christmas wish list to him:

• For all wound care providers to have access to the U.S. Wound Registry’s (USWR’s) Merit-Based Incentive Payment System (MIPS)-approved quality measures via “SMART” apps.
• For manufacturers to sponsor the development of CTP outcome measures.
• For all wound care providers to report healing rates by risk category to the USWR.
• For a taxonomy that identifies wound care practitioners to payers.
• For wound care and hyperbaric medicine practitioners to have the ability to report quality measures as a “virtual group” in 2018 for MIPS bonus money.
• For wound care to be recognized as a subspecialty by the American Board of Medical Specialties in 2018.⁴

The fact is, I’m not worried about the next few months, or even 2018. I’m worried about how we will be able to provide wound care services in the next five years. 

References

1. Gelly H: A New Strategy for Targeted Probe & Educate Medical Review. Caroline Fife MD.com. 2017. Accessed online: https://carolinefifemd.com/2017/11/07/guest-post-by-dr-helen-gelly-a-new-strategy-for-targeted-probe-educate-medical-review

2. Targeted Probe and Educate (TPE). CMS. 2017. Accessed online: www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/targeted-probe-and-educatetpe.html

3. Darrah, J. Measuring the value of wound care certification in a quality-based healthcare system. 2016. TWC;10(10):27-9.

4. Simman R. Pursuing the path to specialized wound care: the ABWMS perspective. TWC. 2017;11(8)10-2.