Every day, I hear from wound care providers running into the same problem: costs are climbing, reimbursements are tighter, and audits are coming faster than ever. Now, Medicare Part B spending on skin substitutes has blown past $10 billion, and the OIG isn’t just raising an eyebrow — they’re sounding the alarm.
If you’re a provider, this isn’t something to skim over. It’s a call to act.
The Numbers That Matter
Here’s what the OIG found:
- Medicare Part B spending on skin substitutes exceeded $10B in 2024 — driven by more use and rising unit prices.
- Most skin substitute claims still come through Original Medicare, even though more than half of beneficiaries are in Medicare Advantage.
- Home-based wound care claims cost roughly four times more than office-based care.
- Patterns that scream risk: providers billing almost entirely for skin substitutes, “stacking” claims to hit payment thresholds, and first-visit applications with no prior conservative care.
Providers billing heavily for skin substitutes without offering other wound care services? They’re showing up on the OIG’s radar as potential outliers.
Why You Should Care
Audits are coming. Claims that used to fly under the radar will now face pre-payment reviews, audits, and even clawbacks.
Patient access is at risk. If reimbursement gets unstable, some providers might cut back on skin substitutes — or leave home-based care altogether. That leaves patients in the lurch.
The system can mislead you. Spread pricing and ASP-based reimbursement can push higher-margin products, even when a lower-cost option works just as well. That’s not just a billing issue — it’s a care issue.
How HealthRecon Connect Helps Providers Stay Ahead
Here’s what we do for clients navigating this storm:
- Audit billing patterns to catch spikes or overuse early.
- ASP reporting guidance to stay compliant.
- Documentation and coding support to validate “reasonable and necessary” use.
- Strategic product selection balancing cost, outcomes, and compliance.
- Internal controls & surveillance to spot irregularities before audits hit.
Structural Reforms We Need
Medicare skin substitute spending won’t stabilize on its own. We need:
- Tighter ASP reporting enforcement and manufacturer accountability.
- Pricing transparency across the board.
- Adjusted reimbursement policies to close home vs office cost gaps.
- Stronger clinical justification for new products.
- Consider reclassifying skin substitutes as supplies to eliminate spread incentives.
Without reform, we risk continued waste, overuse, and unfair penalties on providers and patients alike.
Final Thoughts
Skin substitutes are powerful. But the rules are changing — fast. Compliance isn’t optional anymore.
At HealthRecon Connect, we help providers stay ahead: protecting revenue, ensuring compliance, and keeping patient access intact.
Because at the end of the day, it’s not just about $10 billion in spending. It’s about patients who deserve healing and providers who deserve to deliver it without fear of penalties.