After a New York suburban hospital was audited for inappropriate implantable cardioverter-defibrillator (ICD) procedures based on Medicare national coverage determination (NCD) requirements, a subsequent review found only 15% of procedures deemed questionable lacked a reasonable explanation. Researchers performing the review argue that updates in clinical literature do not match NCD regulations, indicating some of these inappropriate exams have clinically justifiable reasons.
Within their review, Steinberg and Mittal highlight the inherent disconnect in practicing evidence-based medicine within the context of significant regulatory oversight. As the evidence base evolves and influences the way physicians practice medicine, regulators can be slow in integrating this new information when evaluating appropriateness. To combat this, the study’s authors suggest more detailed documentation may provide some safeguard against future scrutiny of this kind.
Expert review questions CMS ICD appropriateness scrutiny
Several weeks ago, the Centers for Medicare and Medicaid Services (CMS) announced the scheduled January 1, 2012 launch of the Recovery Audit Prepayment Review demonstration project to improve payment accuracy for select inpatient services. The project is designed to conduct prepayment reviews to ensure medical necessity is documented and services are justified before receipt of payment for services rendered.
Although CMS recently clarified its policy by outlining the DRGs under consideration and timelines for implementation, the agency has now delayed implementation of the project altogether amid significant controversy and questions regarding the project’s scope and structure.
CMS clarifies, then delays, prepayment review demonstration
Building upon the success of the Medicare Recovery Audit Contractors (RACs) in recouping improper payments for potentially unnecessary health care services, CMS recently announced the “Recovery Audit Prepayment Review” demonstration to conduct prepayment reviews of certain health care services to ensure medical necessity before providers are reimbursed.
CMS doubles down on appropriateness with new prepayment review demonstration