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Cardiac Imaging Medicare Scheme | Great Vessels, Great Outcomes
January 6, 2025
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Together with
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“Every year, fraudulently recoding patients as being sicker than they are to get a bigger Medicare payment costs taxpayers billions of dollars. This needs to stop. The new administration can stop it.”
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New HHS Deputy Jim O’Neill.
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Adding to a relentless trend of Medicare schemes, 16 cardiology practices agreed to pay more than $17.7M to resolve allegations that they overbilled for diagnostic radiopharmaceuticals and violated the False Claims Act.
- In 13 states and D.C., Medicare Part B reimburses providers for radiopharmaceuticals based on self-reported acquisition costs, leaving billing up to the honor system.
- This structure was abused in 12 of these 13 states, highlighting the pervasiveness of cardiac radiopharmaceutical overbilling.
The DOJ accused these practices of reporting “inflated acquisition costs” to Medicare for materials needed to perform cardiovascular imaging.
- Radiopharmaceuticals like sestamibi and tetrofosmin, which are used for cardiac SPECT and CT scans, made up the bulk of overbilling.
- The questionable conduct occurred for at least a year, and in some cases for more than 10 years.
The three largest settlements accounted for nearly two thirds ($11.7M) of the total payment, covering restitution, fines, and accrued interest.
- Western Kentucky Heart & Lung Associates came in first, paying a whopping $6.75M.
- Heart Clinic of Paris paid $2.6M.
- Scranton Cardiovascular Physician Services paid $2.3M.
- Meanwhile, some practices paid as little as $50k to $160k.
- The whistleblowers will make off with $2.7M of the settlement money.
Although the settlements don’t represent an admission of guilt from the practices, they are part of a larger trend of Medicare overbilling that has plagued the U.S. healthcare system. That’s certainly been true within cardiology over the last year.
- Cardiac surgeons at Baylor St. Luke’s fraudulently billed for over 5,000 concurrent surgeries while using residents to perform the procedures.
- Cape Cod Hospital paid an eyewatering $24.3M to resolve billing allegations for pre-TAVR evaluations that didn’t meet requirements.
- An NJ cardiologist submitted $1.9M worth of false claims for office visits that either never happened or were shorter than claimed.
- Cardiac Imaging of Illinois was charged for a kickback scheme that paid referring cardiologists as if they were supervising PET scans when they weren’t.
The Takeaway
While overbilling continues to find new ways to creep into the U.S. healthcare system, the bigger issue is the inevitable strain it puts on Medicare’s ability to help the patients who are actually sick, which begs the question: what will it take for us to stop robbing Peter to pay Paul?
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Reducing ECG Background Noise
Monebo’s Kinitec Rhythms ECG Algorithm separates true ECG signals from background noise, leading to more accurate diagnoses and improved operator efficiency. See for yourself how the algorithm measured up to a gold standard.
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Echo Automation’s Big Impact
Improving clinician efficiency and quality is the goal for most AI solutions, but we rarely see AI achieve both. See how Juntendo University’s Dr. Nobuyuki Kagiyama achieved both of those goals, while reducing sonographer fatigue in the process.
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- Great Vessels, Great Outcomes: An analysis of 47 studies (2,844 patients) comparing great vessel transposition strategies found anatomic repair outperformed physiologic repair, especially when factoring in patients’ age. At the study’s 10 year follow-up, the average mortality risk was lower with anatomic repair (11.7% vs. 17.4%), and fewer patients needed reintervention (24.5% vs. 30.3%). Outcomes were especially good in patients who underwent surgery before 5 years of age and in those who also had preoperative pulmonary artery banding.
- POLARx Cryoablation Recall: The FDA announced that Boston Scientific issued a Class I recall for the catheters associated with its POLARx Cryoablation System due to risk of esophageal damage, which led to seven patient injuries and four deaths. Although this recall doesn’t remove the catheters from the market, it offers instructions for “verifying balloon position, esophageal monitoring, and phrenic nerve monitoring.” Boston Scientific also warned against repeat ablations in the same location, and that ablation should be stopped if balloon temperatures reach -65° C.
- Anteris Completes IPO: Anteris raised ~$88.8M via its NASDAQ IPO, dedicating the funds to the development and testing of its DurAVR transcatheter heart valve. The DurAVR THV mimics the performance of a healthy human aortic valve to replicate normal blood flow using Anteris’ anti-calcification ADAPT tissue. As part of the implantation process, Anteris uses its proprietary balloon-expandable ComASUR Delivery System to insert the DurAVR THV and ADAPT tissue, bringing new competition to a space dominated by giants like Edwards and Medtronic.
- KNO3 Doesn’t Improve HFpEF: A randomized trial of 84 HFpEF patients tested chronic potassium nitrate therapy for exercise tolerance and found its use failed to improve peak oxygen uptake (10.23 vs. 10.17 mL/min/kg), vasodilatory reserve, or quality of life when compared to potassium chloride. Despite theories that nitric oxide deficiency may contribute to exercise intolerance in patients with HFpEF, these findings highlight the challenge of effectively targeting these pathways.
- HF Care At Home: New analysis of the Cleveland Clinic’s Hospital Care at Home program found that acute HF patients can be successfully treated at home. Researchers compared data from 194 at-home care HF patients and 201 hospital care HF patients, finding that 84% of at-home patients completed treatment without needing care escalation. Both groups had similar 30-day mortality rates and GDMT scores, while at-home patients had a lower readmission rate (12.4% vs. 16.9%), though this was not statistically significant.
- University Hospitals’ Robotics Push: One year after starting its robotics program, University Hospitals’ Harrington Heart & Vascular Institute has performed more than 100 heart bypass surgeries using the Da Vinci surgical robot. Harrington now performs eight to 10 robotic procedures per month, a small but growing share of their 1.8k to 2k annual open heart surgeries. UH started with minimally invasive coronary artery bypasses, eventually expanding to robotic mitral and aortic valve surgeries with plans to launch two more robotics programs this month.
- TR’s Organ Function Impact: Results from the TRILUMINATE trial suggest TEER (TriClip + medical therapy) offers a small organ function advantage over standard medical therapy in patients suffering from severe TR. Researchers compared 285 TEER patients to 287 control patients, and found organ function markers remained similar between the two groups at 12 months. However, one subgroup analysis of successful TriClip patients showed small improvements in kidney (eGFR +3.55 vs. +0.07) and liver function (MELD −0.52 vs. +0.34), but the clinical significance of these changes remains unclear.
- BiVACOR’s TAH Advancement: BiVACOR completed the first phase of its FDA Early Feasibility Study with five patients receiving its Total Artificial Heart between July and November 2024. All five patients were implanted with the TAH, received a heart transplant, and were discharged from the hospital, providing the FDA with the data required to expand the study to fifteen more patients. BiVACOR achieved this through the unique design of its TAH which uses magnets and a double sided rotor to pump blood to the lungs and body.
- A Cardiac Fibrosis Gene: Data published in Circulation shows that the paternally inherited Pw1 gene contributes to cardiac fibrosis after ischemic injury. The gene activates the Pfas enzyme, which promotes ECM production, essential for fibrosis. Interestingly, loss of Pfas reduced fibrosis and improved heart function. The authors suggest that targeting the PW1/PFAS pathway could offer a novel approach to treating heart fibrosis and enhancing cardiac repair.
- Careverse’s US Debut: Careverse entered the U.S. cardio AI imaging market with its “Digital Heart” product line that uses AI to measure cardiac anatomy and lesions including vulnerable coronary plaque and peri-coronary fat. The company’s offerings include an FFR-CT algorithm, tools for CAC scoring, and fully automated vessel segmentation and reconstruction of CCTA scans. Careverse has also developed AI applications for brain, chest, abdominal, and breast applications.
- Medicare Payment Fix Dies: A proposal that would have fixed most of a 2.8% cut in the 2025 Medicare conversion factor fell victim to political turmoil over the federal budget last month. The Medicare payment fix was not included in the last-minute continuous resolution passed on December 20th to keep the government running, meaning doctors face reimbursement cuts as the new year begins. Chances are high that legislators will address the cuts during the new Congressional session, as they did in March 2024.
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Merge Cardiology is Best in KLAS
Merge Cardio and Merge Hemo continued their KLAS hot streak, ranking Best in KLAS 2024 for Cardiology and Hemodynamics for the 9th and 12th years. The Merge by Merative cardiology solutions further expanded their KLAS score leads this year, with Merge Cardio scoring 82.8 (up from 82.7 last year) and Merge Hemo surging to 91.5 (from 85.7 in 2023)
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Cardiology AI: From Research to Clinical Practice
Explore how AI algorithms are reshaping cardiology with insights from Tempus’ recent webinar, featuring Dr. David Ouyang of UCLA and Cedars-Sinai, alongside Tempus’ Dr. John Pfeifer and Dr. Brandon Fornwalt. This expert panel dives into how AI can bridge diagnostic gaps, enhance patient outcomes, and streamline workflows for conditions like AFib and pulmonary hypertension. Read the full recap to glimpse the future of AI-driven cardiology.
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An All-in-One Coronary Care Solution
See how HeartFlow ONE is transforming precision heart care as the first all-in-one CCTA pathway, combining FFRCT, stenosis, and plaque analysis in a single workflow.
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- Transforming Ischemia Detection: CCTA AI is poised to transform ischemia detection, leading to far greater diagnostic efficiencies and far fewer unnecessary invasive procedures. See how ischemia’s AI transformation is unfolding in this Cardiac Wire Show interview with Cleerly’s chief medical officer James Earls, MD.
- Optum’s CV Imaging Pearls: As populations age, the increasing prevalence of cardiovascular disease means that pressure is mounting for healthcare providers. Watch Optum Insight enterprise imaging CEO Tracy Byers and Chief Product Officer Omer Shalit-Cohen discuss the important role enterprise imaging plays in cardiovascular imaging.
- Making the Leap to Outsource Post-Processing: Interested in how to outsource cardiac image post-processing, but not sure where to start? PIA walks you through how to assess and compare vendors, understand pricing models and payment options, and outline your requirements to identify vendors who meet your clinical needs.
- Experience the future of learning: Medtronic Academy 2.0 is here! Unlock your ultimate destination for structural heart medical education with the newly redesigned Medtronic Academy 2.0. Gain access to expert-led courses, webinars, and a wealth of resources to stay ahead in cardiovascular care. Visit now!
- A Better Way to Coordinate Post-Stroke Care: Think your EHR messaging system might be holding back your post-stroke care? See how UC San Diego Medical Center streamlined its neuro and EP teams’ post-stroke workflow with Viz Connect, and the impact it had on cardiac monitor placements in inpatient and outpatient settings.
- A Single Cardiac Service Line Platform: Transitioning across multiple imaging platforms is a daily reality for many cardiologists, but it doesn’t have to be. See how three leading cardiac imagers are leveraging Circle CVI’s unified multi-modal software across their diverse caseloads, without switching to other platforms.
- Redefining Percutaneous Coronary Intervention: Learn about the AGENT™ Drug-Coated Balloon from Boston Scientific and how this technology is expanding the treatment options for patients with in-stent restenosis in the U.S. Rx only. (Sponsored by Boston Scientific)
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