CQRC Applauds Expansion of Home Oxygen Therapy Coverage
Home respiratory care leaders remain concerned that subjective medical record review will create unnecessary access barriers for patients
WASHINGTON, DC – The Council for Quality Respiratory Care – a coalition of the nation’s leading home respiratory therapy providers and manufacturing companies – today commended the expansion of home respiratory care services for acute patients in the Centers for Medicare & Medicaid Services’ (CMS) National Coverage Decision (NCD), Home Use of Oxygen and Home Oxygen Use to Treat Cluster Headaches, while also underscoring continued concerns with the agency’s decision to put patient access squarely in the hands of subjective decision-making by Medicare contractors. Historically, these contractors have denied 80-90 percent of claims reviewed because the physician did not write the “magic words” in the patient’s medical record, despite concluding the patient’s objective tests met the medical necessity requirements. This subjectivity places patient access at unnecessary risk.
In the final Decision Memo, which revised two related National Coverage Determinations (NCD), CMS expanded coverage of home oxygen and oxygen equipment for individuals with acute conditions, a move strongly supported by CQRC and its member companies, especially in light of the lessons learned during the COVID-19 Public Health Emergency (PHE). The CQRC applauds coverage of short-term and long-term home oxygen use in both acute and chronic patients as an effective way to enable more patients to move out of the hospital and safely recover at home.
In addition to supporting expansion of patient access, the home respiratory therapy community, including physicians, respiratory therapists, suppliers, and manufacturers, asked CMS to require Medicare contractors to use existing CMS oxygen templates to ensure that the physicians prescribing oxygen know what information is required to support the claim. Unfortunately, CMS decided to rely on medical records that historically have resulted in 80-90 percent of claims being denied. While problematic, suppliers have been able to use a Certificate of Medical Necessity (CMN) to overturn these denials through appeals. Unfortunately, CMS has also removed the CMN, so there will be no objective document to support a patient’s need for the device during the appeals process.
This reliance on medical records with no specific requirements on physicians responsible for completing them could have serious implications for patients. In comments to CMS submitted in July, CQRC expressed concerns over “the practical implications of the proposal to eliminate the Certificate of Medical Necessity (CMN) and subject all claims to only medical record audit review could result in the vast majority of patients – both chronic and acute – losing access to these therapies.”
“We encourage CMS to promptly issue audit guidance to their contractors, physicians, and suppliers specifying that contactors can use the appropriately completed oxygen templates to determine medical necessity,” said Crispin Teufel, Chairman of CQRC. “It is imperative that physicians fully understand what information is required of them and suppliers can accurately determine if documentation is sufficient before placing equipment in a patient’s home so that continued patient access to home oxygen supplies and services is protected.”
The CQRC has long supported the reliance on clear, objective documentation of test results as the basis for establishing medical necessity for home oxygen therapy. Absent the use of objective data in the form of the existing CMS oxygen templates, Medicare contractors will continue to have free reign to deny claims based on an inconsistent and subjective review process that often leads to the unnecessary and unsafe removal of oxygen equipment from patients’ homes.
“Today’s subjective medical record review process is the equivalent to ‘audit roulette’ for home oxygen providers and suppliers, forcing us to operate and treat patients in an environment rife with uncertainty,” added Teufel. “As our sector looks forward to reaching more acute and clinically-appropriate patients through this newly expanded coverage, the need for documentation processes that safeguard patients is increasingly urgent.”
The CQRC looks forward to working collaboratively with both CMS and Congress to advance policy and process solutions such as a CMS pilot program or the adoption of e-prescribing. Ultimately, the CQRC urges CMS and Congress to ensure that only objective clinical data is used when determining if and when a Medicare beneficiary is eligible to receive home oxygen care.
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1CMS Comprehensive Error Rate Testing (CERT) data; 2011-2019.
2ibid.
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About the Council for Quality Respiratory Care
The CQRC is a coalition of the nation’s seven leading home oxygen therapy provider and manufacturing companies. To learn more, visit cqrc.org and follow CQRC on Twitter at @TheCQRC.