The New Near Future of Hyperbaric Medicine Regulation: Targeted Probe and Educate

It is well known in the hyperbaric community that the Centers for Medicare & Medicaid Services (CMS) implemented a prior authorization model in 2015 for non-emergent hyperbaric oxygen therapy (HBOT) in Illinois, Michigan, and New Jersey. This three-year demonstration project ended Feb. 28, 2018.¹ Demonstration projects are subject to review, both internally by CMS and by independent agencies. An internal audit by CMS that was published in 2016 reviewed the results of the first year of the prior authorization of non-emergent HBOT.² Medicare saw a savings of approximately $5.33 million in non-emergent HBOT expenditures and reviewed more than 1,900 prior authorization requests, of which 961 were nonaffirmed. This represents a 50% denial rate. The repercussions of this demonstration project on patient outcomes are presently unknown. However, certain data are available for review and provide some insight into the impact of prior authorization on the provision of HBOT in the United States. CMS tracks services provided by both physicians and by hospitals in the inpatient, outpatient, and office-based sites of service. This data are openly available by CMS. Although there are limitations in the reporting process, these are the same from year to year, so comparison is possible. In order to be reported, a provider/hospital must submit at least 10 claims to Medicare for a Current Procedural Terminology (CPT^®) code or Ambulatory Payment Classification code. CMS’ stance is, if a provider/hospital does not meet this threshold, then the claims are statistically insignificant. A review of the Medicare claims data for CPT Code 99183 (physician or other qualified healthcare professional supervision of HBOT, per session) can be found in Table 1 and shows a marked decrease nationally in the reporting of the code.³ Using the nonaffirmed requests as reported by CMS, 961 (an average of 35 HBOT treatments per patient) would predict a reduction in about 33,635 treatments; however, the reduction was much greater (61,313). The increased denial rate is also reflected in greater scrutiny by CMS intermediaries, both in publically announced prepayment service-specific/targeted medical reviews (Noridian Healthcare Solutions, Novitas Solutions, WPS,^® and Palmetto GBA^®) and random audits. 

Palmetto GBA has been most transparent in the publication of its results, and they are not encouraging.⁴ Looking at claims reviewed between February 2017 and April 2017,⁴ and then between May 2017 and July 2017,⁴ reflects an error rate of more than 60%. This means that many patients who have already received care may not have those services reimbursed to the hospital outpatient department. This high error rate has a number of implications. As the prior authorization project for non-emergent HBOT has come to a close, CMS has instructed all of its intermediaries to implement a new program known as Targeted Probe and Educate (TPE).⁵ This program is designed to “help providers and suppliers reduce claim denials and appeals through one-on-one help.”⁵ The Medicare Administrative Contractors (MACs) use data analysis to identify:

• providers and suppliers who have high claim error rates or unusual billing practices and
• items and services that have high national error rates and are a financial risk to Medicare.⁵

It is definitely of primary importance that all providers of hyperbaric medicine and wound care services fully understand the TPE process and its implications. CMS and the MACs have distributed educational materials on their respective websites, and have sponsored webinars describing the process.⁶ In a nutshell, if someone is identified as an outlier, has a previously identified high claim error rate, or is in wound care and hyperbaric medicine, he/she may be asked to provide the medical records and documents supporting medical necessity for 20-40 claims. These are essentially prepayment reviews. If the documentation is found to be lacking, the provider will have one-on-one educational sessions. This cycle will be repeated three times, after which, if the errors are not mended, the provider may be referred to CMS for further action, including Recovery Audit Contractor audits and possible fraud charges. Although not all of the MACs have identified their targeted areas of interest, a number have included HBOT and wound debridement as areas of interest. Although subject to change, Table 2 above provides a list (as of press time for this edition of Today’s Wound Clinic.) 

It is very important that providers are vigilant in responding to these requests and that they identify recurring themes in “education.” To that end, both the Undersea & Hyperbaric Medical Society and the American College of Hyperbaric Medicine are asking for feedback from the community on TPE. Without understanding the process or the playbook, it will be almost impossible to address areas of concern to CMS and other stakeholders. Consider spending a few minutes reaching out to these organizations to communicate current trends. Although the final assessment of the impact on patients and providers of prior authorization has not been made public, that demonstration project has ended. It has been successful in reducing utilization nationally, expanding beyond the three prior authorization states. TPE has the potential to reduce utilization even further. Providers must be vigilant and work together as the next wave of claims reviews begins. 

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

References

1. Prior Authorization of Non-Emergent Hyperbaric Oxygen. CMS. 2018. Accessed online: www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/prior-authorization-initiatives/prior-authorization-of-non-emergent-hyperbaric-oxygen.html

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. 99183: Hyperbaric Oxygen Therapy. CodeMap.^® 2018. Accessed online: www.codemap.com/cpt.cfm?state=00000&locality=00&cpt_code=9918

4. Gelly HB. Update on prior authorization for non-emergent HBOT: transforming into prepayment review. TWC. 2017;11(10):28-32. 

5. Targeted Probe and Educate (TPE). CMS. 2018. Accessed online: www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/targeted-probe-and-educatetpe.html

6. Improving The Medicare Claims Review Process. CMS. Accessed online: www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/downloads/what_is_tpe-infosheet.pdf