Musings From The UHMS Meeting

It was almost exactly 20 years ago — during the summer of 1998 — that I took over as president of the Undersea & Hyperbaric Medical Society (UHMS). As I write this, I’m at the UHMS annual scientific meeting in Orlando, FL. Being here reminds me of two of the worst years of my professional life: Within a few weeks, the “work component” of the hyperbaric treatment supervision code was reduced to $0.00, the hospital reimbursement rate for hyperbaric oxygen therapy (HBOT) was reduced by 75%, the Health Care Financing Administration (HCFA, the predecessor to the Centers for Medicare & Medicaid Services [CMS]) changed coverage policy so that nonhealing wounds could no longer be treated with HBOT, and the Office of Inspector General (OIG) launched an investigation into the use of HBOT. I did nothing but handle these crises for two years. I honestly thought I would be the last UHMS president. By the time the dust had settled, I understood that when someone in Washington, DC, said you had to “go to K Street,” they might mean it either literally or figuratively. I knew the name of nearly every division director at HCFA, many flight attendants, several congressional staffers, and a few expensive healthcare-policy attorneys. At the conclusion of our final meeting with CMS, when they reluctantly agreed there was a sufficient “evidence base” (a new term then) to make Wagner Grade III diabetic foot ulcers a covered indication for HBOT, the director of coverage policy looked at me as I was leaving and said, “We will be watching.” It felt like the Terminator saying, “I’ll be back.”

In 1998, when a small group of us from UHMS had our first meeting with the OIG in San Antonio, TX, the investigators from the Dallas office showed us the information that had brought HBOT to their attention. It seemed clear to me that a few healthcare facilities in Texas were billing topical oxygen as HBOT. We suggested to the OIG that its investigation could be wrapped up quickly, since they would only need to confirm that no hyperbaric chambers existed at these institutions. However, one investigator mentioned that HCFA was rewriting the national coverage policy for HBOT. This was the first UHMS had heard of it. The result of this revelation was that, within a few weeks, I was in Baltimore to meet with the director of coverage policy, and there sat the same people from the Dallas OIG office. The difference was that now the OIG didn’t care about improperly billed topical oxygen therapy. Suddenly, the OIG was focused on whether HBOT had been improperly billed for chronic wounds. And, coincidentally, coverage policy had decided not to pay for that indication. At the time, it felt like a conspiracy because I didn’t understand that it was really just a collaboration between two U.S. Department of Health & Human Services (HHS) organizations. Two year later, the OIG report concluded that 38% of payments for HBOT were for inappropriate or excessive treatments ($19.1 million). The UHMS had little criticism of the OIG process. The OIG had allowed the UHMS to see the audit tool and even select the hyperbaric physician experts who performed all the chart reviews so that it would be as fair as possible. In fact, today I was talking to one of those physician reviewers. He commented on how transparent the OIG process was 20 years ago. That is not the case with the recent OIG investigation in the WPS Health Solutions region. We don’t know who did the review or what criteria were used. The audit tool has been requested under the Freedom of Information Act, but no one has seen it yet. While we did disagree with a few of the OIG conclusions in the 2000 report, the fact is we did have big problems in the field of hyperbaric medicine in 1998. Documentation was generally sloppy, some treatments were given without a doctor present in the facility, and many patients were not being managed appropriately. On Page 2 of that OIG report, you will find the following statement: “The mission of the OIG is to protect the integrity of the HHS programs as well as the health and welfare of beneficiaries served by them. This statutory mission is carried out through a nationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The inspector general informs the secretary of program and management problems and recommends legislative, regulatory, and operational approaches to correct them.”

 Twenty years ago, I warned everyone that the field of hyperbaric medicine had to get its house in order or we were going to experience those legislative, operational, and regulatory corrective actions. In 2000, the OIG recommended that CMS start a registry of hyperbaric providers and facilities. Personally, I didn’t want CMS to start a registry and force us all to participate. I thought it would be better if we started a registry. That’s why, in 2005, when UHMS wasn’t ready to take such a bold step, my little company decided to do it ourselves. We funded a nonprofit organization that could accept data from any electronic health record, and that initiative became the U.S. Wound Registry and the Hyperbaric Oxygen Therapy Registry. 

Unfortunately, for the past 20 years, I have been playing the part of “crazy” Sarah Connor, warning everyone that an apocalypse is coming. Well, I can finally stop worrying about it —because it’s here. In 2018, physicians and hospitals are facing prepayment reviews, targeted probes, demands for repayment based on new OIG audits, recovery audit contractors, and settling false-claims lawsuits with the U.S. Department of Justice — all pertaining to their hyperbaric billing. Those legislative, operational, and regulatory corrective actions have begun. Unfortunately, because there wasn’t support for a nationwide quality registry, no clinician or hospital will be spared. Thankfully, at least few of us spent the past two decades getting ready. Ironically, it is a battle of the machines. CMS is using data to target providers, and we are using technology to enable compliance with Medicare billing through the quality mechanism. So, as this new chapter begins, I’ll quote Ms. Connor: “The unknown future rolls toward us. I face it, for the first time, with a sense of hope.” Because if you aren’t ready, it is, “Hasta la vista, baby.”