The Challenges and Advantages of Office-Based Wound Care

Change in health care is in the winds these days. The current pandemic has allowed us to explore different ways of delivering health care, both in how we see patients and where we see patients.¹ Although telemedicine might not be ideal for wound care patients, it opened the door to an option of remote supervision of wound care, which was previously inconceivable. Likewise, the shuttering of hospital outpatient departments deemed "non-essential" as the pandemic raged made office-based wound care look more promising. After all, podiatrists have been doing it for years.²

This article will explore some of the advantages and challenges for those in the practice of office-based wound care. Physician office-based wound care is the new frontier—well, new to the folks who are accustomed to providing these services in a hospital outpatient department.

Advantage: Autonomy

The risk of closure of hospital-based outpatient departments (HOPDs) was never as evident as during the first months of the COVID-19 pandemic. Hospitals had to make decisions about the deployment of staff where the need was the greatest. Since there is very little literature to link a reduction in admissions and emergency room visits to wound care visits in the HOPD, it was an uphill battle for many centers to keep their doors open. Compounding this was the reticence of hospitals to allow “visitors” into the main campus, thus limiting access to HOPDs that were on campus.

Most independent practices are either in medical office buildings or in their own buildings. The decision of whether to remain open and continue to see patients was at the provider's discretion. After accounting for inevitable pandemic-related measures, such as no family with the patient, spaced-out visits to reduce encounters in the waiting room, and mandatory screening and mask-wearing, the decision to stay open was not by committee but up to the physician. We never closed our doors in our practice, although we did reduce our volumes to accommodate the measures listed above.

Disadvantage: Isolation

Many of the nation’s HOPD programs are managed by wound care management companies that provide information, education, and monitoring of the regulatory issues that surround wound care. Since so many wound care patients we see are older, they often have Medicare or Medicare Advantage plans. The provider in an independent setting must be willing to keep up with the changes in reimbursement and coverage that seem to happen regularly. There is a degree of isolation from other wound care providers, and participation in wound care focused organizations becomes more critical than ever.

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Advantage: Flexibility in Product Selection

There is a considerable difference in the payment method between the office and the HOPD for supplies and for advanced wound care products, especially for cellular tissue products. In the HOPD, the generous facility fee allows for greater flexibility in choosing your dressings and advanced wound care products such as silver based dressings.³ In the office based payment structure, the cost of the dressings is theoretically included in the practice expense. However, except in rare occasions such as compression dressings, the cost input is for gauze dressings, and does not reflect the current clinical practice guidelines for moist wound dressings and specialty products. The clinician needs to be acutely aware of the cost of the dressings as they are going to be subtracted for the physician reimbursement.

Cellular tissue products, however, are not bundled as in the HOPD. The application fee is separate, as is the preparation fee for the physician. Because of this, there is greater flexibility in choosing the dressing that is most appropriate for the patient. The limitations are the same as the HOPD in that Medicare Advantage plans are requiring prior authorization for CTPs, and many are limiting the choices available to the clinician.

Disadvantage: Financial Liability

In the office-based setting, all the reimbursement is paid through the Physician Fee Schedule. It is imperative that the office-based practitioner has a front office and billing staff that is meticulous about making sure all the required prior authorizations and confirmation of benefits are done correctly. Many times this means calling 2 or 3 times. The physician must be aware of the appropriate coding and language for medical necessity that are required in the chart for possible audits.

All denials need to be vigorously investigated and defended. Since all payments are directly tied to the physician reimbursement, there is no other source of funding to cover the cost of the denial or takeback. Although inevitable in some cases, the recoupment of funds needs to be kept to a minimum, and cannot be “written off” too many times. The traditional billing service is not likely to provide this service, so an in-house reimbursement and recovery specialist may be needed. A specialty billing service should be considered when starting your practice.

Conclusion

As Medicare is relentlessly transitioning to a site neutral payment structure, wound care clinicians need to investigate the possibility of leaving the HOPD and transitioning to an office based model. There is greater flexibility in scheduling hours, increased autonomy and control over your destiny. With that comes greater responsibility and commitment to keeping up with the payment changes that occur at least annually, as well as coding and coverage guidelines.

Podiatry has been pioneering the concept of office-based wound care for years now. The time may have come for others to join the crusade to provide better and more accessible wound care for our at-risk patients, and get out in front of the site-neutral inevitability.

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

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References
1. Rogers, Lee C, Armstrong DG, Capotorto J, et al. Wound center without walls: the new model of providing care during the COVID-19 pandemic. Wounds. 2020; 32(7):178–85.
2. Rogers, Lee C, Lavery LA, Joseph WS, Armstrong DG. All feet on deck—the role of podiatry during the COVID-19 pandemic: preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. J Am Podiatr Med Assoc. 2020; epub March 25.
3. Schwegman D, Gelly HB. A practical guide to establishing a wound formulary in your clinic. Today’s Wound Clinic. 2019; 13(6):10–12.