WASHINGTON, D.C. (July 16, 2021)—The Council for Quality Respiratory Care (CQRC)—a coalition of the nation's leading home respiratory therapy providers and manufacturing companies—expressed concern in response to the Proposed Decision Memo for Home Use of Oxygen and Home Oxygen Use to Treat Cluster Headaches, which outlines proposed changes to documentation requirements put in place to protect providers and patient access by two National Coverage Determinations (NCDs) related to home oxygen. While the CQRC applauds the Center for Medicare & Medicaid Services’ (CMS) proposal to expand access to home oxygen therapy for acute patients, it encourages CMS to reconsider replacing objective testing ordered by a patient’s physician results for the subjective decision-making of Medicare contractors.
“We are highly supportive of allowing acute patients to receive oxygen therapy outside the institutional or hospital setting; however, we are concerned CMS’s proposal would create ambiguity in the system when it comes to demonstrating patient need,” said Crispin Teufel, Chairman of CQRC. “While there have been difficulties with the objective Certificate of Medical Need (CMN) that establishes medical necessity, it has been an anchor during the appeals process when suppliers defend patients’ access to these devices after a contractor has denied their claims. It is essential that if the CMN is removed, CMS adopts an objective template or prior authorization to make sure Medicare approves the patient access. A subjective review process and Medicare Administrative Contractor (MAC) discretion, which, according to historic CMS CERT data, could result in 80% of claims being denied, therefore putting patient access at risk.”
The CQRC has historically supported the adoption of a clear, objective template that identifies the information physicians must include to establish that a patient needs the device. A more subjective approach is troubling because it means that a supplier fills the physician’s prescription and delivers the equipment to the patient only for the Medicare contractor to deny the claim if the documentation does not meet their subjective view. This situation forces the supplier to try to remove the equipment from the patient’s home, even if the physician still believes, in her medical judgement, the equipment is necessary.
“There is no reason to ‘hide the ball’ and make physicians, patients and suppliers guess at what documentation is required before contractors allow patients to use a device their physicians have prescribed for them. All stakeholders must have access to the objective data used to ensure the delivery of timely, quality patient care,” added Teufel.
The CQRC originally submitted comments on NCD 240.2 Home Use of Oxygen in the summer of 2020 and intends to again submit our feedback to the recently proposed decision memo.