Medicare Compliance & Reimbursement

PPOs can hold the key to rehab programs' success.

Providers interested in opening an outpatient wound care center will need to steer clear of a growing number of legal and compliance pitfalls.

Wound care is one of many rehab-related topics that will be under the HHS Office of Inspector General's microscope in 2005. The 2005 Work Plan specifies that the OIG will be looking at "whether claims for wound care services were medically necessary" and billed according to Medicare requirements. The OIG also will examine what providers are doing to prevent inappropriate payments for wound care.
 
To stay in the clear, providers should continue to document the medical reasonableness and necessity of the services they offer, advises Burtonsville, MD-based attorney Elizabeth Hogue.

Nonetheless, providers will be on their way to a successful wound care program if they attract the right patients. Therapists in outpatient programs can provide services for a range of wound patients, including those with wounds from chronic venous disease, osteomyelitis, trauma, and first- and second-degree burns, as well as diabetics with lower extremity wounds, patients observes wound care consultant Mary Foot of Naperville, IL. "Patients with trauma wounds and burns are a big draw for these clinics" because treatment involves both wound care and pain management modalities, such as infrared therapy and E-stim, she notes.

Wound patients with connective diseases such as rheumatoid arthritis and lupus may also be good candidates, but providers treating these wounds should keep in mind that the anti-inflammatory drugs these patients take could hinder healing - lengthening the treatment process, Foot explains.
 
Watch out: Be extra cautious about treating wounds resulting from arterial circulatory problems. A vascular specialist should verify that circulation is restored or is being restored before wound treatment begins. Clinics should not deal with these patients unless they can provide hyperbaric treatment, Foot adds.
 
False Claims Charges Loom

If you're providing substandard wound care and submit a claim for that care, you could be slapped with a false claims violation. "Even if everything on the claim form was actually provided to the patient, it's still a false claim because the care deviates from national standards of care," Hogue explains.

To ensure that you're not putting scalpels into unskilled hands, you'll want your staff certified by either the American Academy of Wound Management (AAWM) or the Wound Ostomy Continence Nursing Certification Board (WOCNCB), Foot recommends. And physicians who open centers should also have wound management certification.

Some uncertified physicians could be "treating patients with outdated protocols, outdated techniques and utilizing substances that may be inappropriate for healing," Foot warns.

If a provider is routinely getting orders for inappropriate care from a physician, the provider should call this to the physician's attention and tell him or her about the appropriate treatment.  A therapist "can't just sit back and say that because the physician ordered the treatment, it must be appropriate," Hogue says.

Editor's Note: To contact the American Academy of Wound Management (AAWM), go to www.aawm.org. For more on the Wound Ostomy Continence Nursing Certification Board (WOCNCB), see www.wocncb.org.