HBOT Prior Authorization & Prepayment Review Forum

TWC offers this exclusive forum for providers in the outpatient wound clinic to share their experiences related to hyperbaric reimbursement and prepayment protocols. To share a comment, email jdarrah@hmpcommunications.com

Anonymous Comment: 
Dear Dr. Fife: Regarding a recent article that appeared in Today's Wound Clinic (Understanding & Responding to Prepayment Reviews for Hyperbaric Oxygen Therapy) author Helen Gelly, MD, FACCWS, UHM/ABPM, FUHM wrote the paragraph below. I'm confused as to whether this is the procedure in the prior authorization program that’s going on in Michigan, New Jersey, and Illinois or if this is related to something else. The reason I’m confused is because when I read the Federal Register notice about the program, it looks like once you submit your documentation, you get a response within 10 days. What’s described below sounds like a process that is a lot longer than 10 days, and even though the program is for nonemergent uses, waiting any period of time that resembles the timeline below seems awfully long. I don’t know how long these wounds can last without treatment, so maybe this is fine and within typical timeframe for you, but I think I’m a bit lost on what’s discussed below.
 
"A recent educational session offered by Noridian identified the steps that part of the POR reviews regarding HBOT. Providers will be notified by letter following the prepayment review and an additional documentation request (ADR) will be sent. Providers must respond within 45 days. If no response is received, the denial is made for “non-receipt of medical records.” If the claim is denied (or if a provider is dissatisfied with the determination), a request for redetermination must be sent within 120 days. The Medicare Administrative Contractor (MAC) redetermination review process allows for 60 days to provide response. Those providers who are not satisfied with the outcome have 180 days to file a reconsideration request with the qualified independent contractor (QIC) working with the MAC. At this level, all supporting documentation that can be foreseen as needed in the provider’s defense (including literature, position statements, and complete relevant medical records) must be submitted. The QIC then has 60 days to respond. If that response is considered to be unfavorable, the provider may go to a third level of appeal — an administrative law judge (ALJ) appointed through the U.S. Department of Health and Human Services. At this level, providers cannot easily submit additional information. Ultimately, there are five levels of appeal: I - Redetermination by the MAC; II - Reconsideration by a QIC; III - Hearing before an ALJ; IV - Review by the Medicare Appeals Council; V - Judicial review by a federal district court." 

Response From Dr. Fife: This is such a good question because it is confusing! Prepayment review is different from prior authorization. First, let's review what prior authorization is. Under prior authorization, which is active in only three states (MI, IL, NJ), BEFORE rendering the hyperbaric service, you are required to send in your records and the MAC has 10 days to make a determination as to whether HBOT is medically indicated and will be covered for the indication requested. Noridian has initiated prepayment review in at least some of the states in its jurisdiction. In this scenario, you have provided the hyperbaric service and have sent in the claim for payment. However, before the MAC pays the claim you have submitted, Noridian requests medical records as part of a "prepayment review." These records are reviewed in their "medical review" department and they have an unlimited amount of time to review the records before deciding whether they will pay you for the services that you have already provided. However, this review usually is completed within 30-45 days. If your claim is denied for lack of medical necessity, you may ask for a "redetermination." 
 
Redetermination is theoretically performed by an independent group, but they utilize the same guidance materials when they review records. This process takes about 60 working days. If denied at the redetermination stage, you may request "reconsideration." Reconsideration is supposed to be an independent audit. This process takes another 60 days. Please note that by this time, the bill you have submitted for the hyperbaric services that you have ALREADY PROVIDED TO THE PATIENT has now gone unpaid for at least five months. The next step is to request a hearing before an administrative law judge. How long it takes for this to happen depends on how busy the docket is, so it can take weeks or months before your case is heard. If denied before the judge, you then have the option of going to court.
 
While prior authorization requires congressional involvement in order to be expanded, the prepayment review process in which you render HBOT services, but then may wait many months to be paid - if EVER, can be initiated by the MAC at any time. It appears that the prepayment review process has begun with Noridian, but is expanding to other carriers. It is important for hyperbaric providers to watch out for any requests for medical records coming from a MAC as part of a prepayment review. If these requests are sent directly to the hospital medical records department and languish there, after 45 days the claim is simply denied for lack of responsiveness.
 
The prepayment review process could actually be a far greater threat to the future of hyperbaric medicine because claims for services already rendered could go unpaid for six months or longer as they work through this process (not to mention the cost of shepherding claims through these steps).  This delay in payment could spell financial disaster for a hyperbaric operation.