Opinion: Simplify Medicare’s Overly Complex Auditing Process for Home Respiratory Care
Reimbursements withheld due to physician errors harm oxygen providers
by Steve Griggs

The article below is the opinion of the author and does not necessarily reflect the views of HomeCare magazine or Cahaba Media Group.

For taxpayers and policymakers alike, the concept of public health care dollars being lost to waste, fraud or abuse is nothing short of sickening. The need is too great, and the amount of resources too finite, to tolerate misuse of funds.

The federal government, to its credit, has taken great strides to clamp down within the Medicare program in order to ensure dollars go where they should and fraud is fully identified and prosecuted. A mountain of checks, balances and roadblocks have been put in place to protect the safety and integrity of our public health care programs and the patients who depend upon them.

But while these fraud prevention solutions are laudable, many are incredibly cumbersome—and even detrimental to the older Americans that Medicare is intended to protect. When it comes to these regulations and requirements, sometimes more isn’t always better. It’s just more.

For example, the providers of home oxygen supplies and services—who serve more than a million Americans with conditions like chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea—are struggling with how to handle Medicare’s overly burdensome prescriber documentation requirements. Under the system, instead of relying on written prescribers’ orders and certificates of medical necessity, these requirements create expansive documentation demands that require prescribers to guess what words contracted claims reviewers will accept to support Medicare paying suppliers for providing medically necessary home respiratory therapy. That's despite a 2018 Centers for Medicare & Medicaid Services (CMS) report stating there was not a single case of oxygen and oxygen equipment suppliers providing supplies and services when the beneficiary did not medically require them.

It’s a process that can delay care, and even creates unreasonable costs and risks that could threaten access to life-sustaining respiratory therapy for Medicare patients.

Imagine if a pharmacist, whose job it is to dispense a drug ordered by a doctor, were held financially responsible for documentation error made by the prescribing physician. Such is the case today when home oxygen providers are held responsible—via withheld reimbursements—for clerical errors and documentation issues originating with the prescriber.

In fact, nearly all of the payments deemed “improper” through CMS’s auditing process are due to insufficient encounter notes, not the actions of providers. Complicating matters, the auditing process is a hodgepodge of confusion: Data elements are not standardized, introducing reviewer subjectivity into the audit process. Without a clear, objective standard, third-party contractors have wide power to deny legitimate claims based on missing words from a prescriber’s record. Some reviewers reject claims because the word “chronic” is not spelled out when a physician writes that the patient has COPD.

More recently, claims for patients with COPD have been denied after their hospital stay for an acute condition because the reviewer failed to see in the record that home oxygen was prescribed because of the underlying COPD and not related to the hospital stay for the acute condition.

The current auditing process works against home oxygen providers and equipment suppliers at a time when the need for their services is on the rise. And it’s hard to imagine an increasing number of providers willing to step up when they could likely be denied compensation for doing their jobs – and providing critical healthcare services in good faith.

CMS has voiced a commitment to put “patients over paperwork” and the home oxygen community would challenge policy makers to do just that.

2020 Budget Concerns

The Council for Quality Respiratory Care was pleased to see President’s Trump’s fiscal year 2020 budget recognizes the need to address long-standing problems with the over-reliance on physician notes in the auditing process and highlighted the commonsense solution of expanding the use of prior authorization to other types of durable medical equipment. Implementing such policies will reduce the cost of providing services to Medicare beneficiaries and save taxpayer dollars.

CMS should follow the lead of many Medicaid programs and commercial insurers by implementing prior authorization for home respiratory therapy. This would allow prescribers to know that they have provided the documentation needed up front to establish medical necessity. Leveraging widely accessible web-based technology, a home respiratory therapy prior authorization program would eliminate the waste associated with overly zealous auditors, while protecting the integrity of the Medicare program. By improving payment accuracy, the administration estimates the prior authorization provision alone would save upwards of $300 million over 10 years.

While Congress should carefully consider ways to address the overly burdensome and costly audit process for home respiratory therapy, the administration has sufficient authority to enact the changes it recommends when it comes to home respiratory therapy. I urge both Congress and the administration to work closely with the suppliers, prescribers and patients to bring balance to a broken system. These are laudable efforts that will more effectively root out fraud and abuse while driving down costs without putting patient care on the line.