The disconnect between the guidelines, the appropriate use criteria, and reimbursement coverage decisions: The ultimate dilemma

Richard I. Fogel, Andrew E. Epstein, N. A. Mark Estes, Bruce D. Lindsay, John P. Dimarco, Mark S. Kremers, Suraj Kapa, Ralph G. Brindis, Andrea M. Russo

Research output: Contribution to journalReview articlepeer-review

17 Scopus citations

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.

Original languageEnglish (US)
Pages (from-to)12-14
Number of pages3
JournalJournal of the American College of Cardiology
Volume63
Issue number1
DOIs
StatePublished - Jan 1 2014

Keywords

  • Appropriate Use Criteria
  • National Coverage Determination
  • guidelines
  • implantable cardioverter-defibrillator

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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