Whistleblowers Who Report False or Inadequately Documented Medicare Claims for Hyperbaric Oxygen Therapy Treatments Are Entitled to Financial Rewards.
The U.S. Department of Health and Human Services (HHS) has announced that investigating false claims for Hyperbaric Oxygen Therapy will be a top priority in 2017. The announcement was made as part of the HHS Office of Inspector General’s 2017 Work Plan.
Hyperbaric oxygen (HBO) therapy involves giving a patient high concentrations of oxygen within a pressurized chamber. Breathing 100 percent oxygen intermittently in a pressurized chamber has been found to be an effective adjunctive treatment for the management of some non-healing wounds.
Medicare provides reimbursement for HBO therapy under certain circumstances. The HHS Office of Inspector General (OIG) has expressed concern, however, that Medicare has reimbursed hospitals and other HBO therapy providers for claims that should not have been paid.
The specific concerns are patients who received HBO treatments for non-covered conditions, patients who received more HBO treatments than were medically necessary, and Medicare claims for HBO treatments that were not supported by adequate medical documentation.
Medicare provides reimbursement for HBO therapy only when the patient has one of the following conditions: Acute carbon monoxide intoxication; Decompression illness; Gas embolism; Gas gangrene; Acute traumatic peripheral ischemia; Crush injuries and suturing of severed limbs; Progressive necrotizing infections (necrotizing fasciitis); Acute peripheral arterial insufficiency; Preparation and preservation of compromised skin grafts; Chronic refractory osteomyelitis; Osteoradionecrosis; Soft tissue radionecrosis; Cyanide poisoning; Actinomycosis; and Diabetic wounds of the lower extremities in patients who meet the following
three criteria: (a) Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; (b) Patient has a wound classified as Wagner grade III or higher; and (c) Patient has failed an adequate course of standard wound therapy.
Because HBO therapy is covered as an adjunctive therapy, the supporting medical documentation must establish not only the patient’s condition, but also the patient’s response to standard treatments. HBO therapy is covered only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy.
The supporting medical documentation must also demonstrate that the HBO therapy is having measureable results. Wounds must be evaluated at least every 30 days. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.
Even if the patient satisfies all the criteria for reimbursement, a claim for reimbursement from Medicare will be considered “false” if the contemporaneous medical documentation does not establish that the patient has been diagnosed with one of the covered conditions, standard wound therapy has not resulted in measureable results for at least 30 consecutive days, and HBO therapy has resulted measureable signs of healing.
Failing to maintain the proper documentation can result in severe penalties, including paying restitution of up to three times the amount Medicare paid and penalties of up to $11,000 per claim. In cases of intentional fraud, criminal charges are possible.
The government cannot uncover false or inadequately documented claims on its own. For that reason, the government provides significant financial incentives and legal protections to whistleblowers. Individuals who come forward with evidence of false or inadequately documented claims to Medicare are entitled to a reward of up to 30% of the amount the government recovers from the HBO therapy provider.
Whistleblowers, however, must follow strict procedural requirements to be eligible for a reward. If you have evidence of false or inadequately documented Medicare claims for HBO therapy, you should consult with an experienced whistleblower lawyer immediately to protect your rights. Call John Howley, Esq. at (212) 601-2728 to schedule a free and completely confidential consultation.