Medically Unnecessary Peripheral Procedures

In recent years, False Claims Act qui tam cases have been filed across the country, alleging that healthcare providers were engaged in Medicare fraud by knowingly submitting claims to government healthcare programs for cardiac catheterizations that were not reasonable or necessary for the diagnosis or treatment of patients. The Justice Department has intervened in and settled many of these actions, placing a spotlight on these medical practices and returning millions of dollars to the Treasury. This increased scrutiny from whistleblowers and the government has potentially contributed to a decrease in the number of procedures to open blockages in heart vessels, decreasing the numbers by about 30 percent from 2005 to 2013.

According to a recent New York Times article, a sizeable percentage of cardiologists have increasingly shifted their practice time away from the heart and are now focusing a larger portion of their time on opening blockages in other parts of the body, such as the arms and legs. In fact, according to the Advisory Board Company, “peripheral” procedures have increased by almost 70 percent from 2005 to 2013.

According to The New York Times, the country’s leading academics argue that these peripheral procedures should only be reserved for those few patients who are at risk for amputation. Moreover, there is a dearth of information in the medical research supporting the widespread use of peripheral procedures.

Nonetheless, a percentage of community cardiologists are routinely submitting claims to Medicare for peripheral procedures. In fact, The New York Times analyzed the 2012 billing records for the top ten billing cardiologists in the country, and discovered that eight of the doctors made about half of their reimbursements from Medicare by performing procedures to ease the narrowing in an artery or vein in patients’ arms and legs.

More information for whistleblowers is located at the Nolan Auerbach & White website.