Update on Prior Authorization for Non-Emergent HBOT: Transforming Into Prepayment Review

It has been more than two years since CMS initiated the implementation of prior authorization for non-emergent hyperbaric oxygen therapy. This update will properly inform new and existing wound clinics alike. 

It has been more than two years since the Centers for Medicare & Medicaid Services (CMS) initiated the implementation of prior authorization for non-emergent hyperbaric oxygen therapy (HBOT). In fact, the end of the project is rapidly approaching. The end date for participating states (Michigan, Illinois, and New Jersey) is Feb. 28, 2018.¹ On Nov. 16, 2016, CMS posted a one-year review of the outcome of the prior authorization project (Table 1).² CMS officials estimate that more than $5.33 million was saved through this process. However, the impact is much greater than just the monetary value. CMS has reportedly received 1,932 prior authorization requests, of which only 917 were affirmed (47%). That means more than 50% of patients were denied care. This troubling trend has expanded insidiously into Medicare Administrative Contractors that are not in the prior authorization by the implementation of prepayment review. Although Noridian Healthcare Solutions LLC, Novitas Solutions Inc., and WPS^™ all announced prepayment service-specific/targeted medical reviews, Palmetto GBA^® has been the most transparent in publication of its results — and they are not pretty: The error rate averages more than 60% and goes as high as 100%. This means that many of those patients who received care will not have those services reimbursed to the hospital outpatient department. There are a myriad of reasons for the denials; however, lack of proper documentation of medical necessity, lack of a physician order for the service, and no valid plan of care top the list.  The denial reason of most concern is “the recommended protocol was not ordered and/or followed” (Table 2A and Table 2B).³ That said, the national coverage determination (NCD) 20.29⁴ has no recommended protocols. This implies that Palmetto GBA, although referencing the NCD as its source document, is actually using an undisclosed metric in reviewing these claims. This lack of transparency in the documentation requirements for payment makes achieving compliance an elusive goal. Only First Coast and Novitas have published local coverage determinations (LCDs), while NGS has an article and Noridian has a pending LCD that has not been finalized in more than 18 months. All HBOT providers should have access to the non-emergent HBOT reason codes and statements⁵ published by CMS as a guide for the documentation requirements. Recent updates include:

• Reason Code HBO1E - Physician order including number of treatments and/or number of units not provided.
• Reason Code HBO1F - Progress updates with response to treatment goals not provided.
• Reason Code HBO3E - The documentation supports there were measurable signs of healing to the wound with the use of standard wound care prior to initiation of HBOT.
• Reason Code HBO3G - Documentation indicates patient is at nutritional risk, but no interventions were provided.

The hyperbaric community must be more attuned to the increased scrutiny and documentation requirements that are surfacing at many intermediaries, putting patient care at risk. If patient care is being compromised due to these arbitrary documentation requirements, then our congressional leaders should be made aware of the risk to their constituents. 

Helen B. Gelly is emeritus medical director of Hyperbaric Physicians of Georgia and chief executive officer of HyperbaRXs, Marietta, GA. 

References

1. Medicare Prior Authorization of Repetitive, Scheduled Non-emergent Ambulance Transport & Non-emergent Hyperbaric Oxygen (HBO) Therapy Demonstrations. HHS. Accessed online: www.cms.gov/research-statistics-data-and-
systems/monitoring-programs/medicare-ffs-compliance-programs/prior-authorization-initiatives/downloads/ambulancehbo_partnerfactsheet.pdf

2. Medicare Prior Authorization of Non-emergent Hyperbaric Oxygen (HBO) Therapy Model Status Update. CMS. 2016. Accessed online: www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/prior-authorization-initiatives/downloads/hbopriorauth_statusupdate_111616.pdf

3. Prepayment Service Specific Complex Review Results for, Outpatient Hyperbaric Oxygen Therapy (HBO), HCPCS G0277 (Hyperbaric Oxygen under Pressure, Full Body Chamber, Per 30 Minute Interval), February - April 2017. Palmetto GBA. Accessed online: www.palmettogba.com/palmetto/providers.nsf/
docscat/providers~jm%20part%20a~medical%20review~results~an2hzp5535

4. National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29). CMS. Accessed online: www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=12&ver=3

5. Non-emergent Hyperbaric Oxygen (HBO) Therapy Reason Codes and Statements. CMS. 2017. Accessed online: www.cms.gov/research-statistics-data-and-systems/computer-data-and-systems/esmd/downloads/nonemergenthbo_reasoncodesandstatements_7317.pdf