That has led to greater financial incentives for whistle-blowers to come forward, for Medicare contractors to investigate tips, and for the CMS computer geeks in Maryland to mount massive data-analysis campaigns on high-cost Medicare procedures.
“The physicians are becoming dramatically aware of this kind of supervision. Some of them are becoming paranoid about it,” said Dr. Spencer King, a cardiologist with the Heart and Vascular Institute in Atlanta and a past president of the American College of Cardiology. “But they really shouldn't be concerned about prosecution or anything if they are providing the care that they said they are providing, and if the (clinical) evidence is there.”
One area of cardiology where evidence of egregious conduct by a few doctors has turned up is in the placement of stents. Federal regulators now routinely insist on 70% stenosis, or coronary blockage, to justify the use of a wire mesh to prop open a blood vessel.
Critics say such bright lines can hamper physicians' autonomous clinical judgment, especially since tests measuring stenosis and other factors can be open to interpretation, as Modern Healthcare wrote about in the print magazine this week.
The best way for any physician to stay out of trouble in a high-scrutiny climate is to follow the clinical guidelines published by professional societies. (Here are the 2011 guidelines published by several cardiology organizations on percutaneous coronary interventions, or PCIs, a rapidly growing nonsurgical procedure that can be used to implant a stent.)
But the key to showing that a particular clinician is following the rules is documentation—an area that has seen as much technological revolution as the procedures themselves.
“Physicians are becoming increasingly aware that they are being watched, and this is driving a great interest in recordkeeping, a great interest in electronic medical records,” King said. “It's going to be very difficult to prove fraud for something that is thoroughly documented.”
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