Review of Outpatient Cardiac Rehabilitation Services - Evanston Northwestern Healthcare, Evanston, Illinois

This review was part of a nationwide analysis of Medicare reimbursement for outpatient cardiac rehabilitation services requested by the Centers for Medicare and Medicaid Services to determine the level of provider compliance with national Medicare outpatient cardiac rehabilitation policies.  The objective of our review was to determine whether Medicare properly reimbursed Evanston Northwestern Healthcare for outpatient cardiac rehabilitation services.  Our review disclosed that the hospital did not designate a physician to directly supervise the services provided by its cardiac rehabilitation program.  In addition, contrary to current Medicare requirements, we could not identify the physician professional services to which the cardiac rehabilitation services were provided “incident to.”  Also, the hospital claimed and received Medicare reimbursement for outpatient cardiac rehabilitation services which did not meet Medicare coverage requirements, which may not have been supported by medical record documentation, or which were otherwise unallowable.  We recommended that the hospital: (1) work with its fiscal intermediary to ensure that its outpatient cardiac rehabilitation program is being conducted in accordance with the Medicare coverage requirements for direct physician supervision and for services provided “incident to” a physician's professional service; (2) work with its intermediary to establish the amount of repayment liability for services provided to beneficiaries where medical documentation may not have supported Medicare covered diagnoses and for services not otherwise allowable; (3) bill evaluation and orientation visits only when performed by physician personnel in accordance with local medical review policy; and (4) implement controls to ensure that medical record documentation is maintained to support Medicare outpatient cardiac rehabilitation services.