The Society’s Leadership Meets with CMS on Medicare Recovery Audit Contractor Program

The Recovery Audit Contractor (RAC) program is currently identifying improper Medicare payments paid to healthcare providers. Improper payments may be overpayments or underpayments; overpayments are recovered by the RAC Program. The RAC program is auditing the appropriateness of Medicare services in both hospitals and physician practices. Payment inconsistencies for patients who receive ICDs and CRT-Ds have been a target of these reviews.

On April 24, 2009 Heart Rhythm Society leaders, N.A Mark Estes III, MD, FHRS; Richard Fogel, MD, FHRS: Hugh Calkins, MD, FHRS and. Richard Page, MD, FHRS met with the RAC medical directors as well as Centers for Medicare & Medicaid Services (CMS) staff overseeing program to discuss concerns with the audit procedures and seek feedback and support for the hospitalization criteria developed by the Society that warrants inpatient admission for ICD and CRT-D implantations. The Society’s main concern is that RAC reviewers in the various Medicare regions are inconsistent in their decisions across similar cases on whether a patient should be admitted as an inpatient or outpatient with observation.

As a result of a first meeting with CMS staff on this issue a year ago, the Society developed a list of criteria that warrant inpatient admission for ICD and CRT-D implantations. Download Guidance Criteria (PDF, 70K). The Society leadership will continue to work with CMS central staff and regional offices, as well as the RAC medical directors to advocate for transparency to our members on the appropriate criteria and processes for determining when hospital inpatient care is required.