Medicare Investigates and Prosecutes False Claims for Physician Supervision of Hyperbaric Oxygen Therapy
The federal government has targeted Hyperbaric Oxygen Therapy companies that submit false and fraudulent claims for reimbursement to Medicare.
In a recent case under the False Claims Act, the owners of HBOT companies were sentenced to five years in prison and ordered to pay restitution of more than $1.5 million for submitting false claims to Medicare for physician supervision of HBOT sessions or dives.
Hyperbaric Oxygen Therapy (also known as HBOT or HBO2) involves giving a patient high concentrations of oxygen within a pressurized chamber. Originally developed for treatment of decompression sickness, HBOT is primarily an adjunctive treatment for the management of select non-healing wounds. Some studies suggest that HBOT may also relieve symptoms associated with traumatic brain injury, but other studies suggest that the evidence is inconclusive.
An HBOT session is called a “dive.” Each dive begins when the patient enters the chamber and concludes when the patient exits the chamber. Physician supervision of the dive usually involves ensuring that the patient’s condition is medically appropriate for the dive and to treat any medical emergency that might arise during the dive, such as a stroke or heart attack.
Medicare reimburses for HBOT dives only if the patient suffers from specific conditions, most of which are related to decompression illness, acute carbon monoxide intoxication, crush injuries, severed limbs, and diabetic-related wounds or other wounds that are not healing.
If the HBOT dive takes place in a hospital, then Medicare reimburses for both hospital charges and physician supervision of the dives.
Two of the most common types of false claims involving HBOT are billing for medically unnecessary treatments and improperly billing for physician supervision.
For purposes of Medicare reimbursement, medical necessity means that the patient suffers from one or more of the conditions for which Medicare will reimburse the service. HBOT companies can get into trouble by billing for HBOT dives ordered by a physician that do not fall within the Medicare reimbursement guidelines, by billing for HBOT dives without proper documentation of the medical necessity, and by creating false or fraudulent documentation.
Physician supervision of HBOT dives is usually billed using Current Procedural Terminology (CPT) code 99183. This CPT code applies only when the physician provided “direct supervision” of the HBOT session. “Direct supervision” usually does not require that the physician be physically present in the same room as the chamber. The physician, however, must be physically present at the site and immediately available to furnish assistance and direction throughout the performance of the procedure.
Under some circumstances, Medicare regulations require that the physician be physically present in the treatment room continuously for the duration of the HBOT session. The supervising physician must be continuously present next to the chamber when the patient has been diagnosed with acute peripheral arterial insufficiency; acute carbon monoxide intoxication; decompression illness; gas embolism; gas gangrene; crush injuries and suturing of severed limbs; progressive necrotizing infections; and cyanide poisoning.
Billing Medicare for HBOT dives that are not medically necessary or for physician supervision that does not comply with the direct supervision requirements is a serious matter. You can be sued civilly for three times the amount Medicare paid plus a penalty of up to $11,000 per false claim. You can also face criminal charges and long prison sentences.
If you have evidence that a hospital or other healthcare provider is improperly billing Medicare for HBOT sessions, then you should consult with an experienced Medicare fraud attorney immediately to protect yourself.
By getting legal advice early, you may be able to avoid criminal investigations and charges. If you help the government uncover the fraud, you may also be entitled to a substantial whistleblower reward and legal protections.