Related Experiment Videos
The disconnect between the guidelines, the appropriate use criteria, and reimbursement coverage decisions: the
Richard I Fogel1, Andrew E Epstein2, N A Mark Estes3
1St. Vincent Medical Group, Indianapolis, Indiana.
Insights
Clinicians face challenges due to conflicting guidelines for implantable cardioverter-defibrillators and cardiac resynchronization therapy. Discrepancies between appropriate use criteria and payer policies create dilemmas for patient care.
Area of Science:
- Cardiology
- Medical Device Technology
- Healthcare Policy
Background:
- The American College of Cardiology Foundation and Heart Rhythm Society published appropriate use criteria (AUC) for implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT).
- These AUCs synthesize practice guidelines and clinical experience to evaluate scenarios for device implantation.
- A recognized discordance exists between AUC recommendations and payer coverage policies, including Medicare's National Coverage Determination (NCD).
Purpose of the Study:
- To address the conflict between established appropriate use criteria for ICDs and CRT and existing payer coverage limitations.
- To highlight the ethical and practical dilemmas faced by clinicians due to these discrepancies.
- To propose solutions for reconciling the disconnect between clinical guidelines and reimbursement policies.
Main Methods:
- Review and analysis of the published appropriate use criteria (AUC) for ICDs and CRT.
- Examination of the implications of Medicare's National Coverage Determination (NCD) on clinical practice.
- Discussion of potential strategies to bridge the gap between clinical recommendations and payer requirements.
Main Results:
- The AUC for ICDs and CRT includes scenarios deemed 'appropriate' or 'may be appropriate' that are not covered by all payers, such as Medicare.
- This discrepancy creates a significant challenge for clinicians aiming to provide optimal patient care while adhering to coverage rules.
- Failure to align with NCDs for procedures could lead to accusations of fraud.
Conclusions:
- The discordance between AUC and NCD creates a dilemma for clinicians regarding patient care versus payer policies.
- Reconciliation strategies are needed to ensure patients receive indicated device therapy without financial or legal repercussions.
- Recommendations are offered to assist clinicians in navigating these complex issues and prioritizing patient well-being.
Abstract:
Recently, the American College of Cardiology Foundation in collaboration with the Heart Rhythm Society published appropriate use criteria (AUC) for implantable cardioverter-defibrillators and cardiac resynchronization therapy. These criteria were developed to critically review clinical situations that may warrant implantation of an implantable cardioverter-defibrillator or cardiac resynchronization therapy device, and were based on a synthesis of practice guidelines and practical experience from a diverse group of clinicians. When the AUC was drafted, the writing committee recognized that some of the scenarios that were deemed "appropriate" or "may be appropriate" were discordant with the clinical requirements of many payers, including the Medicare National Coverage Determination (NCD). To charge Medicare for a procedure that is not covered by the NCD may be construed as fraud. Discordance between the guidelines, the AUC, and the NCD places clinicians in the difficult dilemma of trying to do the "right thing" for their patients, while recognizing that the "right thing" may not be covered by the payer or insurer. This commentary addresses these issues. Options for reconciling this disconnect are discussed, and recommendations to help clinicians provide the best care for their patients are offered.
Related Concept Videos
01:17Ethical Dilemmas I
Let us explore some examples to understand the potentially complex moral decisions nurses face.
Take the case of caring for minors, particularly in areas related to reproductive...
01:27Ethical Issues
Ethical Concerns in Healthcare:
01:30Ethical Dilemmas II
01:15Methods of Documentation VI: Case Management Model
For example, a patient with a chronic illness...
01:29Issues And Trends In Healthcare Delivery System
Cost Containment
Payment for healthcare services has historically promoted adoption of costly and often unnecessary or inefficient...
01:06Legal Guidelines for Documentation