Justice Department Fines 457 Hospitals for Inappropriate ICD Implantations

From the Heart Rhythm Society via email today:

Today, the Department of Justice announced that it has reached settlements in its investigation of hospitals for billing Medicare for ICDs implanted in Medicare patients that did not meet Medicare coverage requirements. The announcement includes 70 settlements involving 457 hospitals in 43 states for more than $250 million.

The Heart Rhythm Society (HRS) has recognized that the misalignment between the Medicare National Coverage Determination and the clinical practice guidelines created gaps between the payment policy and clinical decision-making and places physicians and their patients in an untenable position. To help mitigate the problem, HRS published "2013 HRS/ACCF/AHA Expert Consensus Statement on the Use of Implantable Cardioverter Defibrillator Therapy in Patients Who Are Not Included or Not Well Represented in Clinical Trials”.

Moving forward, the Society’s priority is to do everything possible to assist the heart rhythm care community in managing the patient care pathway. HRS and other medical specialty societies are currently working with the Centers for Medicare and Medicaid Services (CMS) to identify the appropriate time to reopen the existing national coverage policy. The Society will provide CMS with recommendations to update the clinical indications for reimbursement. With this preparation, we stand ready to work with our partners to revise the Medicare coverage policy to reflect current clinical practice.

Outdated CMS National Coverage Decisions from 2005 just whacked hospitals. "Misalignment's" Catch-22. So much for evidence-based medicine. So much for practice guidelines. So much for innovation in health care.

CMS NCDs rule now, no matter how outdated, from now on.

The Justice Department has spoken.

-Wes

References: Justice Department press release with list of hospitals affected.
More on the history of this action here.

CMS Issues National Coverage Decision for Pacemakers Dangerous To Patients

Who needs the Independent Payment Advisory Board to limit indicated care for patients when you have the Center for Medicare and Medicaid Services (CMS)?

Today I learned that CMS has issued a National Coverage Decision (NCD) for pacemakers effective 6 July 2015 that would restrict pacemaker implants to patients with "non-reversible symptomatic bradycardia" and require a so-called "KX" modifier to be added to codes for patients needing pacemakers.

That's right, even patients with asymptomatic complete heart block would not be covered.  Patients with asymptomatic Mobitz Type II heart block wouldn't be covered either.  Even though every piece of medical literature has supported the benefits of pacemakers in these indications, it seems doctors will be left with no choice but to lie in their documentation about patient symptoms to assure Medicare payment, or risk the government refusing to pay for their patients' medically indicated care.

Of interest is the fact that the change request for the new policy references a section of CMS’ claims processing manual. (The red italicized print in CR 9078) However, that section is now suddenly absent from the actual manual.

The Heart Rhythm Society and the American Medical Association (who forwarded this rule change) has been suprising silent on this new decision that was recently forwarded to our nation's hospitals and failed to included "exceptions" to their rules as part of their transmission. As of this morning, no mention of this transmittal has occurred on their website that I could find.

Practicing cardiologists and cardiac electrophysiologists everywhere should be outraged that such a document was circulated to Medicare billing coders everywhere, but not forwarded to US physicians given its implications to patient care. 

I have no doubt Medicare monies will be saved when people die as a result of this transmitted coverage decision as it currently exists. But we should ask ourselves who is responsible for such negligence on behalf of our patients?

-Wes

1930 PM CST - Link fixed (h/t to @drjohnm)