The OIG recently issued a report indicating Medicare Administrator Contractor (MAC) First Coast Service Options, Inc. paid providers for hyperbaric oxygen therapy (HBO) that did not comply with Medicare requirements. The OIG sampled 20 outpatient claims over the time period 2012-2015 and determined there was a 92% error rate resulting in overpayments of $351,970.
The OIG estimates for this time period, First Coast paid providers a total of $39.7 million for HBO therapy that did not comply with Medicare requirements. The audit found the medical records did not always support HBO therapy was provided as treatment for covered conditions and, in some cases, the documentation did not support HBO was provided only after failed standard/conventional treatment. HBO services have historically been associated with high Medicare payment error rates and has been on the OIG Work Plan since November 2016.
Medicare coverage criteria for HBO is outlined in NCD 20.29 https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=12&ncdver=4&bc=AAAAgAAAAAAA&
Additional MAC guidelines may also apply.
HBO is covered only for the conditions listed below. Furthermore, providers must satisfy the supervision, evaluation, and time-based requirements for HBO in order to meet the coverage criteria.
Covered Conditions:
- Acute carbon monoxide intoxication
- Decompression illness
- Gas embolism
- Gas gangrene
- Acute traumatic peripheral ischemia
- Crush injuries and suturing of severed limbs
- Necrotizing fasciitis
- Acute peripheral artery insufficiency
- Preparation and preservation of compromised skin grafts
- Chronic refractory osteomyelitis
- Osteoradionecrosis
- Soft tissue radionecrosis
- Cyanide poisoning
- Actinomycosis
- Diabetic wounds of lower extremities that meet certain criteria
We recommend you perform proactive audits of HBO services to ensure applicable coverage guidelines are being met. The HBE team has over a decade of HBO audit experience and is available to assist you and your facility in conducting these reviews.
The entire OIG report can be found at https://oig.hhs.gov/oas/reports/region4/41606196.pdf