Paula Erwin Toth, RN, MSN, FAAN
By Thomas E. Serena MD, FACS, FACHM, FAPWCA
"Please don't bury me down in that cold, cold ground. I'd rather have them cut me up and pass me all around"
Fans of folk singer John Prine will recognize the homey lyrics describing his views on organ donation. Sitting at my desk a few weeks ago with John Prine twanging in my headphones, I began to slog through the new Noridan Local Coverage Determination (LCD) on hyperbaric oxygen therapy (HBOT). It should not have come as a surprise that the Centers for Medicare & Medicaid Services (CMS) is planning prepayment review for HBOT services. We have been struggling for months in New Jersey, Michigan and Illinois with preauthorization. What is frightening is that a large number of the denials we have seen are completely nonsensical, bureaucratically driven, and dangerous: a patient with osteoradionecrosis of the jaw, for example, was denied because she didn't have 30 days of standard of care; or perhaps the CMS keyword search engine selected out a proscribed adjective!
How does one respond to this Orwellian obsession with arbitrary word usage? If this were a rare occurrence it would be one thing, but many of the denials have no basis in fact, and are designed to delay or prevent the patient from receiving limb and lifesaving treatment, all to meet a government mandate to cut Medicare costs. God forbid that somewhere in the patient's record someone comments that a wound looked slightly better.
Denied! Even if his foot is falling off. Don't save the toes, cut them off!
"You can throw my brain in a hurricane, the blind can have my eyes..."
Hyperbaric Oxygen Therapy Prepayment and Patient Access
My brain blowing about in the LCD hurricane, I studied prepayment review, which led me to an inescapable and unfortunate conclusion: prepayment is far worse than preauthorization. Payment will be denied for HBOT and it may be too late to take corrective action. For example, if a patient is denied treatment because the HBA1C is too high, a frequent occurrence in New Jersey, the clinician will have run out of options. Over time clinicians will stop using HBOT for fear of nonpayment. Our waiting rooms will once again look like a war zone and, ironically, the cost of care will increase.
There is a solution. We have developed a comprehensive plan to conquer preauthorization in New Jersey. It has been successful in decreasing our Medicare denials. In the short term we will institute our algorithm at all of our centers. Interestingly, the plan has increased patient satisfaction. This is most likely the result of the one-stop shopping approach we employ. In the long term, the answer is clinical research in HBOT. We have eight clinical trials in preparation slated to commence this year. Our aim: produce overwhelming proof of need at the outset of a patient's program of treatment.
"Venus De Milo can have my arms, Look out! I've got your nose. Sell my heart to the junk man, and give my love to Rose"
About The Author
Dr. Thomas Serena has published more than 75 peer-reviewed papers and has made in excess of 200 presentations worldwide. He has been elected to the Board of Directors of both The Wound Healing Society and the American College of Hyperbaric Medicine (ACHM), the leading academic society in the field of Hyperbaric Medicine. In 2014 Dr. Serena was elected president of the American Professional Wound Care Association (APWCA). Dr. Serena has opened and operates Wound Care and hyperbaric oxygen treatment clinics across the United States.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.