Deeper Than The Headlines: Allegations Related to Unnecessary Procedures on Dialysis Patients

Welcome everybody to another brief video in our deeper than the headline series. I am CJ Wolf for Healthicity.
And in this series, we we try to just go a little deeper than what you you can read easily in these headlines of compliance or coding types of, settlements or enforcement actions. Now today's, headline that we wanna talk about, the case is not fully finalized yet. We're kind of in the middle of it, but there's been a lot that's been shared.
This case has to do with the nephrology procedures, and imaging procedures on patients with end stage renal disease, people who are getting regular dialysis. And this is taking place in the state of New York, allegedly.
So, again, kind of our disclaimer here is that these are allegations, of of fraud, and they have not and nor do they usually go to trial. Usually, there's a settlement. This one, we don't know yet. They're in the middle of it. So we'll see if it proves to to turn into something or not, but it's interesting nonetheless.
And there there's some insight that we can gain just to you know, what can we learn from this? How can we avoid, noncompliance, you know, even even if this particular case turns out to be nothing or it turns out to be something, we could still learn from the allegations.
Now, what's interesting here is that it's two physicians who were the, qui tam relators or whistleblowers, and they are both nephrologists. And what they're claiming they're it's a long story, and we have only a few minutes here in this video to to kinda go a little deeper into the headlines. But the allegations are, you know, when a when a patient has die is on dialysis, one of the most important things medically is that they have access to their blood system, right, to their their cardiovascular system so that they can remove blood, send it through a dialysis machine, clean the blood, and put it back into the body. But you can't do that just drip, drip, drip, drip. You need a certain amount of volume of blood, and you need constant good access.
And you can't just be sticking, you know, a vein, here and there. And so oftentimes, a surgical fistula will be created. The fistula is when, to simplify things, an artery and a vein are surgically connected.
You get you get a larger flow of blood and the stronger access sites of because people on dialysis are often hemodialysis or getting dialysis, three, sometimes four times a week.
And so for the for a long period of time, years, if not the rest of their lives. And those fistula can sometimes become, they can get clots. They could start to stenose or narrow, and you can get some issues, that's gonna affect dialysis.
But not every patient has that. And what was alleged here is that the the the organization was setting up automatic imaging studies of those fistula even if the clinical criteria did not say it was always medically necessary.
So dialysis was not being effect you know, the effectiveness or efficiency of dialysis was not being affected, but yet these patients were were scheduled for what they call fistulagrams when you inject contrast or dye into the bloodstream and take a picture with an X-ray machine to look and see, is that fistula narrowed? Is there a clot in there? What's going on?
And if there's narrowing, you you might do an angioplasty, which is kind of inflate a balloon. I'm I'm simplifying things here for the short amount of time we have on this video.
But, basically, the allegation by these two nephrologists was that this this organization was setting up automatically doing these diagnostic imaging studies called fistulagrams and then some sort of therapeutic procedure like an angioplasty.
And, what's what's interesting when you read into this a little bit more is they they get into the details of what clinical criteria usually are necessary during dialysis. So if somebody does have some sort of blockage in the fistula or is having some sort of access issues or or potential problems, Some of the clinical criteria, lab work, and those sorts of things, flow, metrics will show that that there could be something wrong with the fistula while the patient is having dialysis. And maybe in those circumstances, it's appropriate then to go ahead and order these imaging studies and then therapeutic studies if the imaging study shows that there's a blockage.
But, because it's pretty common, that that these types of things happen or at least it's not rare, sometimes people might get and, again, these are all allegations, might get overzealous and say, let's just set up patients. Let's be super efficient. Let's just set up patients to have these tests done all the time, right, so that we prevent this. Well, from a Medicare and a Medicaid standpoint, that, in their argument, does not meet medical necessity for doing these procedures.