Well I guess you could call this the first big Medicare step for rationing patient care in a way.  I don’t know of any doctors myself that would put a patient through surgery if it was not needed and I’m sure that speaks for about 99.9% of the all doctors out there. 

Hospitals won’t get paid until an audit is conducted to “make sure the procedures is necessary”.  That’s not a big seller right now with many hospitals making all kinds of cut backs and so many are operating either close to or in the red.  As for the doctors, they could get a “take back” letter, in other words the doctor will be paid but if the audits determine the procedure was not necessary Medicare will want their money back.  Pacemakers are one of the audit items on the list.

Ok so how do they audit?  They use an algorithm to check to see if all the parameters are met for the surgery to take place, so the patient may indeed need the surgery but it if is not documented property, nobody will get paid.  This seems to be all about Medicare documentation, so add that on to billing complexities and it’s getting more complicated all the time. 

What is odd is that this article says they believe that 50% of the procedures are not necessary, but that’s a pretty high number in my opinion, but the analytics bean counter folks don’t see human bodies and only run algorithms.  This sounds like a good place to talk about the up and coming next 12 step program…data abuse and addiction and the fact that the naïve and gullible out there still think that algorithms are 100% of the solutions today, they are part but not the entire solution. 

Data Addiction and Abuse –The Up and Coming Next 12 Step Program Is On the Horizon–Side Effects Include Lack Of Data Quality, Integrity And Spasmodic Algorithms

Boy we have a country of naïve digital illiterates who know nothing about code and never wrote a stick that think algorithms solve all and predict better than they do.  They are hooked and sucked by the marketing out there for sure in government and in business.  BD 

The Center for Medicare and Medicaid Services will require pre-payment audits on hospital stays for cardiac care, joint replacements and spinal fusion procedures, according to the American College of Cardiology in a letter to members. Shares in both industries fell with Tenet Healthcare Corp., the Dallas- based hospital operator, plunging 11 percent to $4.18, the most among Standard & Poor's 500 stocks. Medtronic Inc., the largest U.S. maker of heart devices, dropped 6 percent to $34.61.

The program means hospitals won't receive payment for stays that involve cardiac care or orthopedic treatment until auditors have examined the patient records and confirmed that the care was appropriate, Jerold Saef, the reimbursement chair for the Florida chapter of the American College of Cardiology, wrote in a Nov. 21 letter to members. The review process is expected to take 30 days to 60 days, beginning January 1, Saef said.

"This initiative seems onerous for hospitals and will likely reduce procedure volume because hospitals will begin making sure that every patient meets the coverage criteria," Larry Biegelsen, an analyst at Wells Fargo Securities, said today in an investment note on the audit rules.

The program will cover 15 different medical treatments, including patients getting a pacemaker or defibrillator to regulate the heart rate, a procedure to clear arteries or stents to hold them open, spinal fusion surgery or major joint replacement. While Saef based his letter on information provided by First Coast Service Options, which provides all Medicare services to Florida, Puerto Rico and the Virgin Islands, the association confirmed similar programs in 10 other states, he said.



  1. The Medicare pre-approval of pacemakers and defibrillators is only an initial step to audit unnecessary devices. Defibrillators are being implanted for fainting episodes for young people, particularly if the city has revenue-driven paramedics and a community hospital managed by hospitalists. An example is Hoag Hospital and Newport Beach Paramedics that administer so-called Advanced Medical Services. Newport Beach sells paramedics insurance to residents through telemarketing outsource of Wittman residents. My experience was the Newport Beach Paramedics mistaking doing push-ups at a sports field for being collapsed and administering Midazolam to cause decreased breathing, irregular heart beat and amnesia. The Hoag contracted hospitalists further caused a temporary coma by applying external defibrillators under their so-called Arctic Sun Cooling. The Hoag hospitalists from PacificHospitalists.com did what is known as Revenue Cycle Management RCM to get funding from United Healthcare UHC insurance for implanting a defibrillator despite tests showing no cardiac arrest, no blockage, no cardiac myopathy, low blood pressure, not diabetic and normal brain and spine MRIs. The Boston Scientific rep also was a former nurse at Newport Heart Medical Group. UHC insurance used the implant to telemarket me and upsell more unnecessary services such as remote home nursing, prescription management, and other wellness rouses. Beyond Medicare costs, unnecessary cardiac devices are costly to employers in benefits. Let's hope for the FDA and congressional action to mandate audits for implanting devices in hospitals and the device makers of Boston Scientific, Medtronic and St. Jude Medical.

  2. Thank you very much for adding your comment, much appreciated and I have written too about my senior mother and the marketing end of it. They are in your face just a little too much at times.

    The best one was the battle between Walgreens and her Medicare part D plan on her diabetic strips where as the pharmacist said 2x a day to check glucose was not enough and health insurance folks said fine, she didn't want to waste all the strips that she wouldn't use.

    Walgreens saw this perhaps as "lost business" as if they could urge her to test 3x a day they could sell more strips. She also checked with her doctor and she's been checking her glucose 2x day for about 20 years now but all of a sudden this was wrong?

    Never did either get the doctor involved here either, so who and what are these experts out there?

    After a big battle she's able to keep her original method and scripts for 2x a day and not 3, so I saw this as marketing those strips and after 20 years of doing this, she's not an amateur but sure was treated like she didn't know a thing. When she spoke to her doctor about this, his comment made "go figure".

  3. Very informative Article about medicals Billing dispute ....Thanks for sharing....


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