Georgia hospitals facing federal investigation
by Randy Southerland, Contributing Writer
Atlanta Business Chronicle
Excerpts from the article:
Some of the Georgia’s largest hospitals could face multimillion-dollar losses in Medicare reimbursements, if a new federal investigation finds surgeons do not follow guidelines for patients receiving implantable cardioverter defibrillators.
The review will determine whether hospitals followed National Coverage Decision (NCD) criteria in determining who should receive the small battery-powered electrical impulse generator. The devices, which cost upward of $35,000 each, detect an abnormal heart rhythm that can cause sudden cardiac death, and then fire an electric jolt to restore a normal heart beat....
The federal Centers for Medicare and Medicaid Services (CMS) sets specific guidelines that prohibit the devices being implanted if the patient has received other types of treatments or procedures prior to the surgery, according to Rebekah Plowman, a partner in the Atlanta office of Nelson Mullins Riley & Scarborough, LLP and chair of the firm’s fraud and abuse practice.
“The government found it was pretty easy to go out and use data mining techniques to see if they or any other hospital had billed for codes associated with a heart attack or other [prohibited] procedure,” [Emphasis & color mine] said Plowman. “Then they send a letter to the hospital asking why we shouldn’t collect the fees we paid back from you.”
The NCD criteria prohibits hospitals implanting the device in patients who have had a heart attack within the last 40 days or undergone procedures such as balloon angioplasty or open-heart surgery within the past 90 days. [Again, emphasis & color mine] [Really? They just assume that every patient fits this template does not get this procedure?]
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With the potential for losses so high, hospitals have an incentive to fight the claims.
“What hospitals are doing is hiring lawyers to put everything under attorney-client privilege and then hiring consultants to review the medical records,” said Plowman.
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Critics of the CMS review contend that its guidelines for when a defibrillator can be implanted, which were issued in 2003, are out of date and haven’t kept up with research. Others point to evidence that doctors implant too many of the devices without regard to evidence-based guidelines that result in medical complications.
A recent Duke University study found that surgeons often strayed from the evidence-based guidelines for when defibrillators should be implanted. Those cases that did not follow the professional recommendations were more likely to produce in-hospital complications and even death.
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