To improve patient access to oxygen therapy, we must reform Medicare’s flawed auditing process
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Improving the integrity of the Medicare program is a laudable bipartisan goal for all lawmakers. With as many as 10 percent of Medicare payments being improperly distributed each year, correcting these costly mistakes could result in major savings for Medicare and the taxpayer. But well-intentioned policies to prevent fraud sometimes get in the way of themselves and end up causing more harm than good. This is the conundrum in which many home oxygen therapy providers are finding themselves.

Rather than routing out actual fraud, the Center for Medicare & Medicaid Services’ auditing process for oxygen therapy suppliers – ostensibly designed to prevent Medicare abuse - instead focuses on highly technical documentation issues. This is to the detriment of the approximately 1 million Medicare beneficiaries who depend on oxygen therapy to treat chronic obstructive pulmonary disease (COPD), obstructive sleep apnea and other respiratory conditions.

For many oxygen therapy suppliers, it means a ten-fold increase in the number of auditing requests. This is in spite of a CMS contractor’s own assertion that nearly 100 percent of beneficiaries who are prescribed home respiratory therapy do, in fact, meet medical necessity requirements. When you look closely at the data, it becomes apparent that 91.2 percent of so-called “improper payments” for home oxygen therapy were the result of incomplete paperwork or missing documentation (which prescribers, not home respiratory therapy suppliers are required to complete) rather then a true lack of medical necessity. Yet, the denial of services is so plentiful and so egregious that Medicare ends up overturning 80 percent of cases on appeal, after a lengthy, complicated and ultimately unnecessary process. Administrative law judges overseeing the appeal process have found that auditors have denied claims after ignoring submitted documentation and misinterpreting regulatory requirements.

The costs of this broken auditing system are massive. Suppliers are often forced to cease services until their appeal process for denied payments plays out – which can take three years or more. All the while, patients face heavy out-of-pocket costs and may have to go without care, which in the case of many Medicare beneficiaries in need of home oxygen is dangerous and potentially life-threatening.

Although CMS’ efforts to rout out fraudulent activity are commendable, maintaining a system that is highly inefficient, costly, inconsistent and burdensome to both providers and Medicare is not the answer. We need common-sense solutions that eliminate unnecessary and overly burdensome practices while ensuring that vulnerable patients with multiple comorbidities can continue to access quality care. 

Fortunately, it’s beginning to look like momentum is on the side of reform. CMS is actively reviewing its current policies and has repeatedly stated that it is interested in developing a less burdensome, more effective reimbursement system. Meanwhile in Congress, the House Ways and Means Committee recently launched the “Red Tape Relief Project,” which has asked for stakeholder input on how to reduce legislative and regulatory barriers in the Medicare program.

On the behalf of the home respiratory therapy community, I have a few ideas about where to start.

First, CMS’s process for fighting fraud needs to be reoriented towards weeding out actually fraudulent suppliers rather than focusing on technical documentation requirements not in the control of the suppliers – which leads to auditors overzealously searching for technical errors.

Second, the duplicative face-to-face examination and requirement that the prescriber’s medical record contain certain information worded just right, (but which the CMS does not tell prescribers), should be eliminated and CMS should instead establish medical necessity using a signed Certificate of Medical Necessity.

Third, patients and providers would benefit from a modification of CMS’ proof of delivery requirement to allow for alternative documentation options, and policies to prevent contractors from auditing the same patients using different dates of service.

Saving taxpayer dollars by fighting fraud is a useless effort if we are caught in a never-ending cycle of costly and ineffective auditing practices. It’s time that CMS work smarter, not harder and streamline the cumbersome auditing process into one that catches bad actors while preserving patient access to quality respiratory care.

Dan Starck is chairman of the Council for Quality Respiratory Care and CEO of Apria Healthcare.