Latest denial targets prior treatments for oxygen

‘We're trying to get a handle on what they are looking for’
Friday, May 18, 2012

YARMOUTH, Maine – An oxygen patient may seem like a “slam dunk,” but if the medical records don’t show that he’s tried other treatments first, Medicare may deny a provider’s claim.

That’s a lesson that an increasing number of providers are learning the hard way, industry stakeholders say.

"Medicare is going a step further and saying have you tried and failed all other treatments prior to oxygen, which isn't something on the CMN," said Lelia Wilkerson, director of Heritage Medical in Burlington, Iowa. "But when you get to that point of using oxygen, you might use an inhaler but you still need the oxygen."

Under the prevailing standard of treatment for COPD, oxygen is not added to a patient's treatment plan until they reach the most severe levels of the disease. Prior treatments include, among other things, respiratory medications and pulmonary rehab.

Where providers are running into trouble: The documentation for prior treatments may be so old it’s impossible to track down or it’s non-existent, stakeholders said.

"Documentation for those interventions may have occurred long ago, and are, quite candidly, so standard that the referring physician may perhaps not think to add notes regarding what took place in the plan of care months or years ago," said Kelly Riley, director of The MED Group's National Respiratory Network.

That puts HME providers in a tough spot, stakeholders say.

"Who are we to tell the doctor whether he's tried prior treatments?" said Clark Robichaux, president of Oxy Care Equipment Company in Wilmington, N.C.

Furthermore, just because the medical record doesn't specifically note that the patient has "tried and failed" on other treatments doesn't mean he doesn't need oxygen.

"These patients are on stuff that covers all these other issues and they are hypoxic so the doctor writes the order for oxygen," said Sam Jarczynski, president of RxStat in St. Petersburg, Fla. "It's a slam dunk oxygen patient."

It doesn't help that some providers are seeing blanket denials, stakeholders say.

"We're trying to get a handle on what they are looking for," Jarczynski said. "We don't really know."

CMS needs to play a bigger role in educating physicians about what is needed to ensure access to oxygen therapy, rather than leaving it to providers, stakeholders say.

"At current reimbursement rates, HME providers don't have the added resources to provide this component," Riley said.