Medicare prides itself on putting patients over paperwork.
But for the more than 1 million Medicare patients with serious respiratory illnesses such as chronic obstructive pulmonary disease — the country’s third-leading cause of death — cumbersome regulations threaten to restrict patient access to the doctor-prescribed respiratory therapy to keep patients at home with a better quality of life.
The regulations in question have a worthy goal: ensuring patients who receive home oxygen supplies and equipment have legitimate medical needs, an outcome that is strongly supported by the industry and American taxpayers alike.
In practice, the Centers for Medicare and Medicaid Services requires home oxygen providers to undergo an overly burdensome auditing process that forces companies to obtain and review thousands of pages of patient records created by physicians, not the suppliers. It imposes these documentation requirements on top of the also required, yet much less resource-intensive, certificate of medical necessity.
Moreover, because data collecting and reporting requirements are not standardized — and overly subjective criteria have been added by contractors to what had been objective requirements — many patients have been unable to receive timely therapy because a third-party contractor denied their claim based on missing information from a prescriber’s record. In fact, the overwhelming majority of payments that are deemed by CMS to be improper are caused by insufficient physician medical record notes, not nefarious supplier practices.
Ironically, this scattershot, needle-in-a-haystack approach is itself wasteful because it does not make systematic efforts to investigate credible allegations of fraud. Moreover, fraudulent billing in the home oxygen industry is exceedingly rare: According to a 2018 CMS report, there was not a single case of oxygen and oxygen equipment suppliers providing supplies and services when the beneficiary did not medically require them. Because the broader provider community takes a zero-tolerance policy to fraud, virtually 100 percent of patients who are prescribed home oxygen therapy were determined to meet the medical necessity requirements by their doctors.
Unfortunately, the burdensome auditing rules drastically increase the costs of compliance for a sector already under serious strain. Over the last decade, there has already been a drastic 66 percent decline in the number of home oxygen providers across the country — especially in rural areas. If current trends continue, patient access to medically necessary home oxygen supplies and equipment will be significantly disrupted even further.
The facts are clear: Even though virtually all “improper” claims are due to insufficient information from physicians, home oxygen providers and the patients we supply pay the price when claims get denied. As trusted providers, it is not the role of the home oxygen industry to come in between patients and their doctors; we merely supply the therapies that doctors prescribed. Yet, we pay for the supplies we deliver upfront and, if the “magic words” known only to the contractors are missing, we incur significant financial burdens when the paperwork prevents Medicare from properly reimbursing us for following doctors’ orders.
As much as providers want to continue serving in our communities, financial uncertainty is causing many home oxygen suppliers to go out of business or stop offering respiratory therapies to patients. This is a tragedy — and an entirely avoidable one at that.
To ensure sustained access to home oxygen for patients with serious respiratory diseases, CMS must streamline the auditing process. Protecting against fraud is critical, yet so is supplying life-sustaining therapies to vulnerable patients.
To make it easier to do so, CMS should eliminate duplicative face-to-face examination requirements and instead rely on certificates of medical necessity and prescriptions completed by patients’ doctors. Effectively reforming the process also means standardizing data elements in order to remove the subjectivity third-party contractors use to unfairly deny legitimate claims simply because the “right” words are missing from the documents.
Additional documentation should only be required by CMS when fraud is suspected, helping to unburden law-abiding providers and channeling taxpayer resources to legitimate investigations. Meanwhile, contractors should not waste time and taxpayer dollars auditing the same patients over and over again — especially if no evidence of wrongdoing is found.
Alex Azar, secretary of the Department of Health and Human Services, already has the discretionary authority to eliminate the face-to-face examination requirements and other cumbersome regulations. I urge him to do so quickly so that Medicare beneficiaries can continue to receive the home oxygen therapies they need to survive and thrive.
Dan Starck is chair of the Council for Quality Respiratory Care and CEO of Apria Healthcare.
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