Respiratory Care Providers Press CMS For Post-PHE Guidance


Respiratory therapy providers are calling on CMS to issue unwinding guidance for the sector as the COVID-19 public health emergency comes to an end after raising concerns that the agency hasn’t clarified what providers need to be doing to ensure the nearly 1 million patients who began using oxygen during the pandemic don’t lose coverage.

President Joe Biden on Jan. 30 told lawmakers that the administration will end the national emergencies connected to the COVID-19 pandemic on May 11, setting a ticking clock on emergency health policies.

But as flexibilities for documentation requirements lapse, and as Medicare audits waived during the PHE return, stakeholders including the Council for Quality Respiratory Care are calling on CMS to issue a roadmap for the wind-down period so patients who began receiving oxygen during the pandemic don’t lose coverage.

Respiratory care stakeholders are primarily concerned about CMS’ new medical record-only review, which CQRC said would make it more challenging for physicians and suppliers to demonstrate that a patient medically requires supplemental oxygen therapy.

CMS on Jan. 1 began limiting proof of medical necessity to information gleaned from patients’ chart notes, the lobbyist said. But CMS waived certain documentation requirements and clinical requirements that are usually a part of onboarding patients at the beginning of the PHE, meaning many of the patients who began respiratory therapies during that time do not have the necessary notes to fulfill the agency’s requirements.

Medicare Administrative Contractors would likely deny between 75% and 90% of claims if the review system is implemented, CQRC said in a February release, because the MACs may not find patients’ medical records support the physician’s decision to prescribe the therapy.

Crispin Teufel, chair of CQRC, said the agency hasn’t indicated whether Medicare patients who began accessing respiratory therapies during the PHE will be grandfathered into the system, or whether they’ll need to meet with their providers to have the waived documentation completed after the PHE concludes, Teufel said. But if CMS opts not to grandfather those patients into the system, it could create an enormous backlog of patients looking to meet with their providers before May 11.

A lobbyist told Inside Health Policy that audits are set to begin at the conclusion of the PHE, but patients without completed paperwork could pose a problem for providers, even though they weren’t required to meet those standards during the PHE.

CQRC is hoping CMS will opt to grandfather these patients in terms of documentation requirements and has called on CMS to issue clear guidance on the documentation suppliers need to acquire from physicians so home respiratory therapy patients don’t lose access.

“A clear commitment by, or guidance — for all patients that were set up during the pandemic that are still on therapy — on how to treat them, so namely to grandfather them, that will be a clear commitment that will significantly ease the transition and provide or ensure continued access to care for all of those patients,” Teufel said. “That’s probably the most immediate, most urgent point that probably needs to happen.”

Home respiratory stakeholders are also calling on CMS to implement a standard clinical data elements oxygen template to help with documentation problems, CQRC says in a release, which would outline information providers would need to share with Medicare Administrative Contractors to support each claim. This would lower the uncertainty for providers and prevent inappropriate denials, CQRC says.

Teufel said he’s not optimistic CMS will have policies in place to seamlessly transition into post-PHE care on May 12, but added CQRC is mostly looking for a commitment from the agency that it will work toward implementing the proposed template.

“I think just a sheer commitment by Medicare to acknowledge that we do need a pilot or a program to show them how beneficial [the template] could be for all parties involved, from the physician to the provider, to the patients and to others, I think would be the right signal to show that they’re at least willing to move down that pathway and get away from those manual review processes of chart notes and looking for the magic words,” Teufel said.

The lobbyist said CMS previously developed such a template, but never required providers to use it. If CMS opted to require an electronic template, it could pull information from patients’ electronic health records, the lobbyist said, and could be integrated into providers’ systems to make it easier to complete.

“The Medicare home respiratory program — and frankly DME generally — is in a kind of backwater,” the lobbyist said. “[Respiratory therapy providers] believe it is time to finally modernize the program and the adoption of an electronic clinical data element template, that can interface with electronic medical records for electron data submission is a natural, straightforward thing to do. It’s not complicated to prescribe oxygen, but there are things you need to provide. The mystery to the supplier and physician community is why this process can’t be done electronically, pulling the necessary information out of an electronic medical record. But it is — it has been a real challenge. And several members of Congress have written to CMS on this over the years, most recently in August of last year.”

Respiratory therapy stakeholders have also sought CMS’ support of electronic prior authorization for supplemental oxygen as a fallback option, Teufel said, though he added that’s off the table at present given the pressing timeframe for ensuring patients remain able to access care.

“I think electronic prior authorization as an interim fix — I’d leave that off the table because I think it would require infrastructure that’s absolutely not there given the number of patients being set up on a monthly basis,” Teufel said. “I think the hesitancy on a prior authorization, especially on oxygen, has always been the response times from any Medicare contractor being willing to review the physician’s request in a timely manner, to be honest. … [Prior authorization] was only a fallback option for us because everything else didn’t seem to work. In our opinion, literally the best choice for physicians and for patients is the electronic submission of the clinical information contractors need to assess medical need.” — Bridget Early (


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 and follow CQRC on Twitter at @TheCQRC.