The U.S. Department of Justice (DoJ) recently announced settlements of more than $250 million as a result of its investigation of hospitals billing Medicare for implantable cardiac defibrillators (ICDs) that did not meet Medicare coverage requirements.
The large scope of this investigation, apparent by the list of 457 hospitals included in the settlements, highlights the prevalent gap that exists between Medicare coverage requirements and current evidence-based clinical practice. The Heart Rhythm Society (HRS) has recognized the discrepancy and has been proactively pursuing opportunities to update the existing national coverage policy to ensure alignment between clinical evidence and reimbursement requirements.
"Today, we have a situation where physicians use their best clinical judgement to reduce patients’ risk of life-threatening arrhythmias, while faced with the difficult task of meeting Medicare coverage requirements that do not properly reflect current clinical practice. Collectively, we must work together to solve this issue and adapt to a changing environment that aims to optimize patient care," stated John D. Day, MD, FHRS, President of the Heart Rhythm Society.
As part of our mission, we regularly issue expert consensus statements indicating best practices for clinicians. In 2013, HRS, with the American College of Cardiology and the American Heart Association, published updated recommendations for patient eligibility to receive an ICD: “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. ”
"Because guidelines are mainly determined by the outcomes of large clinical trials, smaller patient populations or unique circumstances are typically not provided with indications for treatment," stated Fred M. Kusumoto, MD, FHRS of the Mayo Clinic in Jacksonville, Florida.
As discussions around Medicare policy move forward, we will continue to work with our partners to ensure that Medicare reimbursement policies reflect current evidence-based medicine. We have always and will continue to advocate on behalf of our members and for the overall advancement of the field of electrophysiology. We are prepared to address this challenge head on and ready to take the necessary actions to change reimbursement policy.
As a Society, we are dedicated to improving the care of patients by promoting research, education and optimal health care policies and standards.