Penalties for overutilization, abuse and fraud in these cases can be severe. A court may assess three times the amount of damages for each claim, plus significant civil and possible criminal penalties.
Portland, OR (PRWEB) April 19, 2011
AllMed Healthcare Management has introduced CardioAudit, a first-of-its-kind service for the systematic review of hospitals’ cardiac procedures to ensure they are medically necessary. AllMed, in partnership with Physician’s Compliance Network (PCN), has developed the service to help hospitals avoid stiff financial and legal penalties levied against their cardiologists for performing procedures and surgeries that fail to meet established standards and guidelines for medical necessity.
In a webinar and white paper presented recently to hospital administrators, medical directors, and heads of cardiology departments, AllMed described CardioAudit as an external peer review program that systematically evaluates specific cardiovascular procedures to determine their medical necessity. It evaluates these procedures—including cardiac catheterizations and implantation of stents—against guidelines set forth by professional medical societies, and criteria established by federal regulations of the Centers for Medicare and Medicaid Services. This allows hospitals to identify potential overutilization in advance of outside auditing, and to take remedial action and other corrective actions that protect all parties.
AllMed’s webinar cited a recent study published in the Journal of the American Medical Association, which found that more than 20 percent of patients who received implantable cardioverter-defibrillators (ICDs) did not meet evidence-based criteria for implantation. Patients who did not meet the criteria were at higher risk of in-hospital deaths and complications following implant.
Further, a recent presentation at the American College of Cardiology (ACC) 2011 Scientific Sessions, looking at data on over 500 000 coronary procedures (including coronary stents) performed from July 2009 through June, 2010, showed a wide variation from center to center in the rate of inappropriate intervention in non-acute patients, ranging from below 10% to over 30%, with a median of 10%.
Penalties for overutilization, abuse and fraud in these cases can be severe. According to Gregory Cohen, MD, MPH, FACC, and AllMed’s partner in the development of CardioAudit, “A court may assess three times the amount of damages for each claim, plus significant civil and possible criminal penalties. This can lead to adverse publicity for physicians and hospitals, causing damage to reputations and negative impacts on revenues.”
Cohen spoke of one Southeast hospital, where one of its cardiologists was investigated for implanting more than 500 stents that were not medically necessary. While not admitting to any wrongdoing, the hospital agreed to pay $22 million in settlement fees. “Had the hospital utilized a preemptive external review process such as CardioAudit, this physician’s practices in all likelihood would have been uncovered and dealt with and the financial penalties and reputation damage could have been avoided.”
According to AllMed CEO, Andrew Rowe, CardioAudit adds to AllMed’s extensive set of external peer review offerings, which supplement hospitals’ internal peer review processes. “Internally-performed peer reviews have inherent challenges, such as conflict of interest and timeliness. Outsourcing these reviews to an unbiased third party tackles these issues head-on, assures that physician performance is objectively evaluated, and gives a hospital the means to tighten clinical criteria and provide additional training to physicians.” Rowe added that external peer review can also help hospitals reduce malpractice and litigation costs by identifying and correcting overutilization and/or sub-standard physician performance before the full consequences are borne by the hospital. AllMed has developed an ROI model for external peer review which it uses to help hospital develop programs and estimate the cost savings over time.
The CardioAudit process starts with sending a statistically valid sampling of cases to AllMed for review by its panel of cardiologists, all of whom are in active practice and are board certified in interventional cardiology, cardiothoracic surgery, electrophysiology, and/or peripheral vascular disease treatment. For all selected cases, copies of angiograms are reviewed and each physician’s work is scored based on guidelines established by the American College of Cardiology (ACC) and the American Heart Association (AHA). The hospital receives a report that includes the scoring, an in-depth clinical indications review, an overall history for each case, and a summary narrative from the reviewer.
“This provides the basis for remedial action to be taken with each physician when appropriate, and a plan for attending to essential follow-up issues and action items,” Rowe said. “Further, because reviews are conducted externally by a large network of physicians, they can be done faster and more economically, and they can be done on an ongoing basis which improves compliance with evidence-based guidelines and significantly reduces the likelihood of high-cost liability claims.”
Cohen added that hospitals will continue to face pressure to demonstrate that their invasive and expensive cardiology treatments result in improved outcomes for patients. “Programs like CardioAudit will help meet these challenges, and give administrators and medical executive committees the ability to identify and correct potential problems before they occur.”
About AllMed Healthcare Management
Founded in 1995, AllMed is a URAC-accredited independent review organization (IRO) serving leading hospital groups, ASCs, insurance payers, and medical management firms, nationwide. More than 400 licensed and board-certified physicians in active practice conduct AllMed’s evidence-based peer reviews. The company’s PeerScore products meet or exceed The Joint Commission standards for OPPE and FPPE evaluations. More information about AllMed can be found on the company’s Web site at http://www.allmedmd.com, and more information about CardioAudit is presented in both a white paper and a data sheet.