Heart disease is the leading cause of death in the United States. As a result, cardiologists frequently rely on stress tests to assess a patient’s risk profile and develop an effective diagnosis and treatment plan. In many cases, cardiac stress tests are covered under Medicare; however, that is not always the case, and, in recent years, the number of cardiologists named in federal healthcare fraud investigations has increased significantly. As a result, cardiologists must be aware of the regulations related to cardiac stress testing and remain cautious when billing Medicare for stress tests. At The Criminal Defense Firm, our healthcare fraud defense attorneys have centuries of experience defending providers from all types of Medicare fraud allegations. Several of our senior attorneys have significant experience working within the federal government, both in a regulatory and law enforcement capacity. This provides us with unrivaled knowledge of how the government conducts stress test investigations and what can be done to help our clients avoid government investigations that may lead to civil or criminal liability.
Are Cardiac Stress Tests Covered Under Medicare?
The Centers for Medicare and Medicaid Services (CMS) approves reimbursement for cardiac stress testing in some but not all cases. CMS has issued several Local Coverage Determinations regarding the scope of approved stress testing. Generally, stress tests are covered in the following situations:
Patients exhibiting signs or symptoms of coronary artery disease, including:
- Angina pectoris or anginal equivalent symptoms,
- Cardiac rhythm disturbances,
- Unexplained syncope,
- Heart failure, or
- Significant atherosclerotic vascular disease elsewhere in the body.
Patients with metabolic disorders known to cause coronary artery disease, including:
- Syndrome X, or
- Atherogenic hypercholesterolemia.
Patients with an abnormal electrocardiogram that is consistent with coronary artery disease.
Patients in need of a pre-operative assessment who are at intermediate or high risk for coronary artery disease.
Patients in need of evaluation when information from the clinical assessment does not adequately assess functional capacity when such information is needed to manage the patient
Additionally, CMS provides certain situations in which stress testing is specifically not covered. These situations include:
- Stress tests ordered to screen for coronary artery disease when there the patient is not exhibiting signs of symptoms;
- Stress testing to motivate a patient to make lifestyle changes;
- Stress testing ordered to qualify a patient for an otherwise uncovered service;
- Pre-operative stress testing for an uncovered surgery;
- Pre-operative stress testing for a covered surgery without the proper documentation supporting a finding that the test is reasonable and necessary.
However, Local Coverage Determination L38396 provides an extremely detailed list of situations in which non-emergent outpatient stress testing is covered. For example, LCD L38396 clarifies the situations in which stress testing is medically reasonable and necessary if cardiac imaging has been performed and when it has not. This LCD also provides a list of 14 “limitations.” For example, below are a few of the situations in which stress testing is not considered medically reasonable or necessary:
- Routine screening for patients with diabetes;
- Routine stress testing in asymptomatic patients with obstructive or nonobstructive CAD without a revascularization procedure;
- Stress testing whenever the results will not affect patient management decisions; and
- Routine stress testing in asymptomatic patients with abnormal prior stress imaging.
Cardiologists are subject to strict regulations when it comes to seeking reimbursement for stress tests. Additionally, the federal government appears to have recently focused enforcement efforts on cardiologists for the improper billing of stress tests. Thus, it is imperative cardiologists not only understand when Medicare covers cardiac stress tests but also that they document all compliance efforts.
How Cardiologists Can Avoid Federal Government Scrutiny When Ordering Cardiovascular Stress Tests
Given the regulatory landscape in which cardiologists operate, it is essential providers take the necessary steps to ensure they remain in compliance. Below is a list of some of the most important considerations when ordering cardiovascular stress testing for Medicare patients.
Understand the Medicare Reimbursement Guidelines
As summarized above, the Medicare guidelines relating to cardiac stress testing are extraordinarily complex. However, this does not excuse a provider’s unfamiliarity with the regulations. CMS assumes that all cardiologists understand the billing rules and guidelines. Thus, even in the event of an innocent mistake, CMS may initiate an investigation. While familiarizing oneself with these guidelines is time-consuming, it is also essential.
Create a Comprehensive Compliance Program to Ensure Consistency
The best way for cardiologists to avoid federal government scrutiny when ordering Medicare-covered stress testing is to develop a comprehensive compliance program that identifies practice-specific risk areas and appropriately addresses them. According to the U.S. Department of Health and Human Services Office of Inspector General, a cardiologist should ensure any compliance program contains the following components:
- Provides for internal monitoring and auditing.
- Creates compliance and practice standards.
- Designates a compliance officer or contact.
- Provides for the appropriate training and education.
- Responds appropriately to detected offenses and develops corrective action.
- Creates and fosters open lines of communication with employees.
- Enforces disciplinary standards through well-publicized guidelines.
Keep Meticulous Records of Medical Necessity
Understanding Medicare guidelines and developing a comprehensive compliance program are critical; however, even these efforts will fall short in the face of a federal investigation if a provider fails to keep detailed records of medical necessity. The Local Coverage Determinations pertaining to cardiovascular stress testing make it clear that the government’s concern about these procedures is that they are often not medically necessary. So much so, in fact, that the federal government may even pursue claims against cardiologists who order covered tests but cannot present documentation of medical necessity. Thus, cardiologists should devote significant effort to developing an organized document-retention system that clearly shows they considered the eligibility criteria for stress tests.
Are You Facing a Federal Healthcare Fraud Investigation Based on Improperly Billed Stress Tests?
If the CMS, DOJ, or HHS-OIG is looking into your practice based on allegations of healthcare fraud due to improperly billed cardiovascular stress testing, reach out to The Criminal Defense Firm for immediate assistance. At The Criminal Defense Firm, our dedicated team of federal healthcare fraud defense lawyers has more than a century of experience defending providers from all types of Medicare fraud allegations. We are immediately available to speak with you about your case and can get to work developing a compelling defense at a moment’s notice. We also work with cardiologists and other providers to develop comprehensive Medicare compliance programs. To learn more about the services The Criminal Defense Firm provides, give us a call at 866-603-4540 or contact us online.
Dr. Nick Oberheiden is a national litigation and trial criminal defense attorney who practices exclusively in the area of federal law.