Medicare will require Prior Authorization of Non-Emergent (HBO) Therapy in 2015

-By Roque Wicker

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CMS has just announced that starting March 2015 three states (Illinois, Michigan, and New Jersey) will be required to get “Pre-authorizations” for the next three years for non-emergent hyperbaric treatments for the following indications:
1. Chronic refractory osteomyelitis
2. Diabetic lower extremity wounds (Wagner 3 and above).
3. Osteoradionecrosis.
4. Preparation and preservation of compromised skin grafts and flaps.
5. Soft tissue radionecrosis.
6. Actinomycrosis.
The decision was made due to “high incidences of improper payments for these services”.

Authorization times will vary from 10-20 business days and as little as 2 days for “imminent” treatment for a life or limb threatening indication.

According to the memo A provisional affirmative prior authorization decision, justified by the beneficiary’s condition, may affirm up to 36 treatments in a 12-month period.

To read more about this please click the links below:
Insurance news HBO article

CMS prior auth process

CMS prior auth (PA) HBO presntation

The Relationship Between HBO Patient Education, Patient Satisfaction, Compliance, and Reimbursement

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Have you ever wondered why your patients quit hyperbaric therapy? Why would they quit despite the fact that they could potentially lose a toe or a foot? Sure a certain percentage of them are claustrophobic, some of them listened to their archaic physicians negative viewpoint of HBOT, some just do not care and have given up, then there are the ones we put in that “uncategorized box” because we really couldn’t pinpoint their rational, instead we categorize these patients simply as “NON-COMPLIANT”.

Are these patients really non-compliant or are they just uninformed and improperly educated? One should ask, “Who in the right mind would sacrifice losing a limb vs going in a chamber for two hours a day watching TV to save the limb in question?” Ask yourself the same question and if you are educated enough and informed enough (and not out of your mind) about the pros of HBOT and the cons of losing a limb, you surely wouldn’t opt for an amputation if you knew there was a possibility of saving that limb. So back to my original question, Why? Is there a possibility that the patient/s were not properly educated on how hyperbaric therapy works and the importance of “daily” treatments explained to them in a way they could understand? In this article I would like to describe the important relationship between improved and effective patient education, patient compliance, patient satisfaction, and value based reimbursement.

Read the whole article here: THE RELATIONSHIP OF PT EDUCATION ON HBO COMPLIANCE PT SATISFACTION AND REIMBURSEMENT

The Relationship Between HBO Patient Education, Patient Satisfaction, Compliance, and Reimbursement

Image

Have you ever wondered why your patients quit hyperbaric therapy? Why would they quit despite the fact that they could potentially lose a toe or a foot? Sure a certain percentage of them are claustrophobic, some of them listened to their archaic physicians negative viewpoint of HBOT, some just do not care and have given up, then there are the ones we put in that “uncategorized box” because we really couldn’t pinpoint their rational, instead we categorize these patients simply as “NON-COMPLIANT”.

Are these patients really non-compliant or are they just uninformed and improperly educated? One should ask, “Who in the right mind would sacrifice losing a limb vs going in a chamber for two hours a day watching TV to save the limb in question?” Ask yourself the same question and if you are educated enough and informed enough (and not out of your mind) about the pros of HBOT and the cons of losing a limb, you surely wouldn’t opt for an amputation if you knew there was a possibility of saving that limb. So back to my original question, Why? Is there a possibility that the patient/s were not properly educated on how hyperbaric therapy works and the importance of “daily” treatments explained to them in a way they could understand? In this article I would like to describe the important relationship between improved and effective patient education, patient compliance, patient satisfaction, and value based reimbursement.

Read the whole article here: THE RELATIONSHIP OF PT EDUCATION ON HBO COMPLIANCE PT SATISFACTION AND REIMBURSEMENT

Should All Hyperbaric facilities be “Required” to be UHMS Accredited?

is it worth it autum

We want to hear from you. How do you feel about the UHMS being the “sole source” surveyor for all hyperbaric facilities in the United States?

Will New HBOT centers get Medicare reimbursement if this happens?

DRAFT-LCDOh boy! They did it again! If you have been asleep (like I have) or simply blinked – I think it’s time to wake up and smell the “regulations”.  Yes, the regulations, I said it.  You are now regulated from the minute you wake up till the second you go to bed (and even when you sleep), and the part that will affect all of us that you may want to familiarize yourself with is NOW here -UHMS ACCREDITATION.   I thought that if I ignored the subject that it would just wither and die but it didn’t -so here we are.  Novitas (a Medicare middleman or as aptly named MAC) -that is “Medicare Administrative Contractor” has now come up with new items on their menu that they would like to FORCE down your throats in respect to the payment for hyperbaric oxygen therapy.

They (Novitas) have drafted an LCD (surely with the help of the UHMS) that will require ALL hyperbaric centers that bill Medicare and/or see Medicare patients be “UHMS ACCREDITED” prior to being reimbursed for the HBO treatments.

It says Specifically: “IT IS REQUIRED THAT FACILITIES RECEIVE AN ACCREDITATION SURVEY BY THE UNDERSEA & HYPERBARIC MEDICAL SOCIETY”  What if you receive an accreditation survey and do not pass? Nothing here states that you must pass in order to get reimbursed right?  Would proof of a check to the UHMS be good enough to “prove” you “received an accreditation survey?”  Hmmmm…..moving on.

What kills the above statement is from the UHMS accreditation guidelines itself:  “A clinical hyperbaric facility is eligible for
an accreditation survey by the Undersea & Hyperbaric Medical Society if it: 1. has been providing hyperbaric treatment services for at least one year before applying for an on-site survey”

Although surely the “intent” is to ensure that all hyperbaric facilities are providing safe, effective, efficacious, and high quality therapy to their patients, the unintended consequences may outweigh its original intent.  Let’s hypothesize for a second – If  “facility A”  in a hospital opens its doors to start treating Medicare patients with HBOT but is required to have its doors open for a minimum of one year prior to receiving UHMS Accreditation (as defined in page 6 of the UHMS Accreditation Guidelines) – who wins?  Does this present a Catch 22?  Surely some brainiacs out there have thought this over.  Does this, and will this minimize the growth of hyperbaric facilities?  Is this the actual intent?  After all the UHMS will be making a killing at around $5000 per facility that they accredit (if just 400 hospitals are required to get accredited the UHMS stands to make at least $2 mil).  Who else wins?  Novitas and CMS of course.  They wouldn’t have to reimburse newer hyperbaric facilities for at least 1 year – but then again, who in the right mind would open a facility if they knew that a majority of the treatments wouldn’t be covered/paid for?

Clearly from just the examples above we have far more questions generated than answers, and as a former LA Council Official I would vote to table this draft until someone “clearly” defines how it would affect a whole industry and not just one entity.  What now?  Well we all wait and hope that the BOHICA moment is delayed for some better regulation that is more sensible and economically viable for all hyperbaric facilities.   In the meantime, you may as well start getting prepared because as you know -ANYTHING CAN HAPPEN.

NOVITAS DRAFT LCD

UHMS ACCREDITATION MANUAL