Medicare Compliance & Reimbursement

Talk about a PR and legal disaster: Media reports that a prominent cardiologist at a hospital may have implanted stents in patients who didn't need them. That scenario continues to play out for a Maryland hospital in a case that provides a cautionary reminder for hospitals to think through how to prevent a similar situation or at least nip it in the bud.

Bad news: The Maryland hospital where the surgeon practiced has "sent letters to hundreds of patients... telling them that the extensive stents in their arteries may have been placed there unnecessarily or under false pretenses," states an article in the Baltimore Sun (www.baltimoresun.com/news/maryland/bal-md.stent29jan29,0,6780233.story).

The take-home message: Hospitals can get caught in the crosshairs when physicians practicing at their facilities get hit with allegations of providing unnecessary care. "Hospitals can't just say 'the physician ordered it,'" says Leatrice Ford, RN, founder of ConsultCare Partners in Louisville, Ky.

Beware: This Isn't the First Case

The Maryland case "is reminiscent" of one in Redding, Calif., "where patients had open heart surgery without indications" for the procedure, says Ford. And it's similar to one in the South where a cardiologist was doing a "ton of drug-eluting stents," which did raise suspicions among some people. But the doctor "was doing the procedures at multiple facilities, so no-one was really policing it," Ford says. Even so, "once the government caught on, all the hospitals got fined. The medical necessity for doing the procedure just wasn't there."

Cardiologists aren't the only ones who've landed in the hot seat for allegedly performing unneeded surgeries. Last spring, two prominent neurosurgeons stood accused of the same at a prominent New York hospital, according to media accounts. And there have been reports of other cases involving different specialists over the years, which could pick up speed in a compliance climate that seems to favor whistleblowing.

Attorney Jason Caron notes that, "a hospital could have liability related to a physician providing allegedly medically unnecessary services," depending on the "specific facts and circumstances." (He emphasizes that he's not referring to any specific case or parties.)

In brief, the hospital's liability in a case often hinges on whether the hospital was involved in or knew about the issue -- "or could reasonably be expected to know" about it, says Caron, with Epstein Becker & Green in Washington, D.C.

Hospitals can take a number of steps to identify and investigate scenarios that raise red flags:

1. Examine a surge in big-ticket procedures. "When a hospital sees significant growth in a procedure or service line," it should have a quality assurance process examining the procedure's medical necessity -- and monitoring outcomes, says Ford. "Unfortunately, administrators are so excited about the boom in business, they don't want to look into whether the business is being conducted properly."

Common warning: One way hospitals usually discover a physician may be providing unnecessary procedures or services is when recipients of the care experience poor outcomes, says Suzan Berman, CPC, CEMC, CEDC, coding and compliance manager for surgery/anesthesia for the University of Pennsylvania Medical Center.

2. Flag physician practice patterns that seem out of whack. That's the other way hospitals usually detect potentially unnecessary procedures, says Berman. Suppose, for example, that the "best cardiologist around is doing 100 stents a year" whereas a lesser known or unknown cardiologist is doing three times that many, she adds. In such a case, Berman suggests asking: Are stents all that the latter doctor does? What else is the prominent cardiologist doing? Is the cardiologist doing three times as many stents getting referrals from other physicians? Is he really doing all of these? Are they all necessary?

People should be asking these questions "long before a situation gets [out of hand]," warns Berman.

3. Investigate any complaints or concerns. In most cases, the hospital administration is usually aware that people have made accusations about unnecessary procedures, but fails to check out the allegations, Ford observes.

"Even if the accusations come from a competitor or an employee, the hospital should investigate those accusations immediately using an outside auditor."

In cases involving what turn out to be unnecessary cardiac procedures, "quite frankly, the staff in the cath lab had to know what was going on," Ford points out.

4. Audit surgical procedure documentation for medical necessity on a routine basis. That approach can head off payment denials for appropriate services, as well as flag a pattern of services that don't meet Medicare or other payers' medical necessity criteria. You have to "be familiar with coverage criteria for procedures (especially Medicare)," says Ford, noting that some procedures, such as carotid stents, have very specific coverage criteria.

(Editor's note: Physicians can also give their practice patterns a check-up to see how they compare to prevailing standards of care. For details, see the next issue of Medicare Reimbursement and Compliance.)