The Disconnect Between the Guidelines, the Appropriate Use Criteria, and Reimbursement Coverage Decisions

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 th...

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Bibliographic Details
Published in:Journal of the American College of Cardiology 2014-01, Vol.63 (1), p.12-14
Main Authors: Fogel, Richard I., MD, Epstein, Andrew E., MD, Mark Estes, N.A., MD, Lindsay, Bruce D., MD, DiMarco, John P., MD, PhD, Kremers, Mark S., MD, Kapa, Suraj, MD, Brindis, Ralph G., MD, MPH, Russo, Andrea M., MD
Format: Article
Language:English
Subjects:
Appropriate Use Criteria
Beneficiaries
Cardiology
Cardiovascular
Clinical medicine
Clinical trials
Fines & penalties
Fraud
guidelines
Heart attacks
Heart failure
implantable cardioverter-defibrillator
Internal Medicine
Medical records
Medicare
National Coverage Determination
Physicians
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Summary: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.
ISSN:0735-1097
1558-3597
DOI:10.1016/j.jacc.2013.07.016