Issues & Insights

Medicare Reforms Needed To Protect Continuity Of Care For Patients

Over the course of the pandemic, Americans have become more aware of the critical role oxygen, ventilation, and other types of respiratory therapy play in the lives of patients struggling to breathe. Respiratory supplies and equipment, long below the radar of most people, suddenly entered the forefront.

While I hope the COVID-19 situation improves and the public health emergency (PHE) comes to an end, the home respiratory therapy industry will continue facing challenges as we strive to maintain patients’ access to care well into the future. To successfully meet the needs of both chronic and acute patients and ensure continuity of care, policymakers must clarify requirements for documentation and auditing.

Home respiratory care has long been an important clinical pathway for patients with serious disease who want to maintain quality of life and live more independently. From amyotrophic lateral sclerosis (ALS) to chronic obstructive pulmonary disease (COPD), the fourth-leading cause of death in the United States, home respiratory supplies and equipment have helped patients to breathe with assistance without being institutionalized. Home oxygen, sleep, and ventilation therapies improve patient outcomes, reduce the need for hospitalization, and enhance quality of life. 

When COVID-19 struck, treating patients safely at home became increasingly important. Home respiratory providers responded to the call, using their decades of experience to help ensure seriously ill patients could continue receiving the treatments they need. With the help of important Medicare flexibilities – including the extension of Medicare payments to treat patients with acute conditions and the decision to exclude home oxygen supplies and equipment from Medicare’s Competitive Bidding Program – we successfully ensured accessibility and continuity of care despite facing unprecedented supply chain challenges and shortages. In turn, our efforts helped ease the burden on hospitals battling a capacity crunch.

We are proud of the work we’ve done and commend Medicare for extending such critical flexibilities during the pandemic. To ensure patients’ uninterrupted access to home respiratory care, however, it is important that Medicare adopt smart regulations after the PHE ends.

First, Medicare must make a technical adjustment to its September 2021 national coverage determination (NCD) that expanded home respiratory coverage to acute respiratory patients. Providers are grateful for this NCD, as it empowers us to serve more patients throughout the country; yet it signals that the Centers for Medicare & Medicaid Services is changing documentation requirements in a way that removes objectivity about patient need. Instead of relying on the previous Certificate of Medical Necessity (CMN) standard to determine if a patient truly requires home respiratory care, the NCD now indicates that Medicare contractors may rely on a patient’s medical record to make a judgment on clinical need and payment. Historically, this medical record review has been incumbent on contractors finding a few “magic words” from the prescribing physician. When contractors have relied upon the medical record, they have denied more than 80%-90% of the audited claims. However, these decisions have been overturned during appeals that rely upon the objective CMN documentation.

Medicare should use the opportunity of the new NCD to modernize this documentation requirement and adopt an objective template physicians can use electronically to submit the information contractors require to support patient need so it is once again objective and unambiguous. A mandated oxygen template would go a long way in streamlining the process and ensuring patient care is not disrupted.

Second, Medicare must clarify the audit process to strike the appropriate balance between accountability and patient access. In the interests of patients, Medicare paused auditing at the outset of the pandemic, but now the future is unclear. Will physicians be forced to requalify all home respiratory patients after the PHE ends? While we strongly support efforts to enhance transparency, we fear that such a process would interrupt medically necessary care and burden a health care work force that is already stretched thin. Fortunately, Medicare seems receptive to our concerns, and we look forward to continuing the conversation with policymakers on how to best streamline the audit process.

In the years ahead, home respiratory therapies will continue to be vital for the well being of Americans with respiratory illness. Ensuring continuity of care is a top priority for home respiratory suppliers – and regulatory flexibilities during the pandemic have gone a long way toward helping us meet the needs of our patients. At a time of increased costs and surging demand, it will be vital for Medicare to streamline the documentation and auditing processes so that patient care is not disrupted. We look forward to being a partner in finding the right solutions.

Crispin Teufel is the chairman of the Council for Quality Respiratory Care and CEO of Lincare.

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