Contributor: Objective Documentation Protects Patient Access to Home Oxygen Therapy

Facing the challenges created by the COVID-19 pandemic, the US medical community has been forced to rapidly change and modernize the manner in which it delivers health care over the last year-and-a-half.

Since March 2020, the use of home respiratory care has skyrocketed to meet patient demand and providers have readily stepped up to reduce the burden on hospitals overwhelmed by COVID-19 cases. As hospitalizations surged, home oxygen therapy played an even more pivotal role in safely transitioning patients from hospital to home. This is in no small thanks to Medicare’s flexibility and expansion of home respiratory care services for acute patients during the public health emergency.

The need for home oxygen therapy shows no signs of abating. More infectious variants are spreading, and there continues to be a trend in unvaccinated Americans contracting COVID-19, stretching hospital resources thin. Alarmingly, we are also seeing a growing population of long-haulers who require oxygen support for months after a COVID-19 diagnosis. Of course, there are also millions of American seniors and others with chronic illnesses and severe respiratory diseases who already rely on home oxygen therapy.

The challenge to provide care to so many patients has put an incredible strain on the home respiratory therapy community. But it has also presented a tremendous opportunity for Medicare to make much-needed and long-awaited improvements.

Most recently, CMS issued a new national coverage determination (NCD) expanding coverage to acute patients in need of home respiratory care, a move strongly supported by both patient and provider groups. However, the NCD also included changes to the documentation requirements used to “prove” patient need that unfortunately could put patient access in peril due to lack of objective criteria.

By eliminating the use of the Certificate of Medical Necessity (CMN) and instead requiring medical necessity to be determined based on the individual prescribing physician’s notes through the subjective decision-making by Medicare contractors, Medicare has essentially removed the only mechanism for considering objective data when determining patient need.

Historically, contractors have denied 80% to 90% of claims reviewed using medical record notes because the notes do not meet their standards. Upon appeal (usually 1-2 years following the initial provision of the services), objective administrative law judges reviewed the CMN to reinstate the claims. Without objective documentation of medical need, contractors will likely deny most home oxygen therapy payment for patients who are in clinical need of our care. For the seniors and chronically ill patients who rely on us, the documentation changes represent the wrong policy at the wrong time.

It makes little sense that the ability of providers to deliver care, and for patients to receive it, depends on the subjective opinions of Medicare’s third-party contractors on a claim-by-claim basis. Given what’s going on in health care, it’s ludicrous that physician decisions are being overwritten by contractors who feel that certain details might be missing from voluminous patient records.

As our nation’s medical community tries to streamline care and facilitate easier patient access, it’s time for Medicare to do the same for home oxygen—stabilizing policy and reimbursement. Perhaps the most important way is a simple one: Eliminate the use of the medical record for determining patient need and instead require the use of clear, consistent, and standardized Medicare templates for the prescription of home oxygen.

These existing CMS templates will ensure that physicians prescribing oxygen know what information is required to support the claim and ensure their patients receive the supplemental oxygen they prescribe. Doing so will eliminate the second-guessing and routine unwarranted denials from Medicare’s contractors.

The entire home respiratory therapy community—physicians, respiratory therapists, suppliers, and manufacturers—has a frontline role in the COVID-19 pandemic that has gripped our nation. We are committed to caring for Americans who are suffering from COVID-19, in addition to our aging population with conditions like chronic obstructive pulmonary disease and chronic respiratory failure. Effectively doing so, and keeping up with unprecedented need, depends on policymakers lifting regulatory barriers that threaten patient access to clinically needed care.