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Based on interview, policy review, and record review, it was determined the facility failed to review professional services provided to determine medical necessity and to promote the most efficient use of available health facilities and services.

The findings include:

An interview conducted on February 23, 2011, at 12:30 p.m., with a physician member of the quality assurance committee revealed that the physician had never reviewed any medical records or cases regarding the medical necessity or the overutilization of cardiac catheterizations.

An interview conducted on February 23, 2011, at 4:00 p.m., with the Quality Officer revealed there was no utilization practice used for outpatient procedures including Cardiac Catheterization. The procedure revealed the cardiologist completed the "Pre-Cardiac Catheterization Orders" form that included "indications" and sent the form to the scheduler at the hospital to schedule the procedure; however, there was no review for medical necessity for these professional services. The Quality Officer also stated that the hospital did not verify or review medical procedures in the outpatient setting for medical necessity on a random basis.

An interview conducted on February 24, 2011, at 12:50 p.m., via telephone with patient #1 revealed the patient had undergone approximately 20 heart catheterizations and the patient's primary care physician could not understand why the patient had to have so many of these procedures. Patient #1 stated the last cardiac catheterization was done when the patient went into the hospital because of severe pain related to kidney stones. Patient #1 routinely had undergone a cardiac catheterization annually even though no changes were indicated from the last catheterization performed and the patient had no current symptoms or complaints.

An interview conducted on February 24, 2011, at 2:00 p.m., via telephone with patient #2 revealed the patient had undergone a cardiac catheterization even though there was no prior history of heart problems. Patient #2 was diagnosed with colon cancer and had an increase in blood pressure after a colon resection surgery. Patient #2 stated that a "drug induced" stress test was performed at the cardiologist's office and the test was "positive." Patient #2 stated the cardiologist never discussed the risks, benefits, or alternatives to treatment, but scheduled a cardiac catheterization for the patient. Patient #2 stated the cardiac catheterization revealed no heart problems.

A review of the procedure for Cardiac Catheterizations revealed the pre-cardiac catheterization orders and the pre-cardiac catheterization history and physical were the only documents the hospital used to ensure medical necessity for a cardiac catheterization. However, there was no evidence of utilization review for the medical necessity for these professional services.

A review of the policy and procedure for Utilization Review revealed the policy/procedure did not include a review of medical necessity for outpatient professional services.

Record review revealed that between January 1, 2010 and December 31, 2010, the facility conducted 3,667 cardiac catheterizations to include both inpatient and outpatient. There was no evidence the facility reviewed these professional services for the medical necessity of outpatient services.