More evidence that doctors in certain geographic areas order a lot more unnecessary tests comes from a new federal report suggesting questionable ultrasound scans for Medicare patients in 20 counties where they are performed more often per beneficiary.
The recent U.S. Office of Inspector General report, which looked at 2007 numbers, could mean another specialty field may be targeted for more scrutiny and spending cuts in an effort to rout out inefficient health spending and waste.
Going forward, the report recommends that CMS "should examine claims for characteristics" consistent with unnecessary overuse and make sure they are legitimate prior to payment.
If they are not, "it should take steps to revoke (providers') Medicare billing numbers. Toward that end, we will provide CMS with information on the providers that we identified as having submitted high numbers of questionable ultrasound claims." One problem highlighted is that in many potentially fraudulent cases, the doctor never billed Medicare for examining the patient before the ultrasound was given.
The big-spending counties include Miami-Dade, Palm Beach, Charlotte, St. Lucie, Broward, De Soto, Marion, Indian River, and Sarasota in Florida; Kings, Nassau, Suffolk, Queens, and Richmond in New York; Willacy in Texas; Union, Middlesex ,and Ocean in New Jersey; Macomb in Michigan; and Walker in Alabama.
For example, in the top-spending county, Kings, NY, 35% of Medicare beneficiaries received ultrasound tests in 2007 at an average charge per beneficiary of $235. Kings was followed by Miami-Dade, FL, with $232, Nassau, NY, $202, Willacy, TX, $195 and Suffolk, NY, $181. In the rest of the counties in the U.S., ultrasound spending was $55 per beneficiary.
Five characteristics of possible ultrasound claims fraud
In analyzing county-level claims files in the high use counties compared with other counties and in consultation with a fraud examiner, the IG "identified five characteristics that may indicate questionable ultrasound claims."
For example, in the higher-use counties, a prior service claim from the doctor who ordered the scan was more likely to be absent, which "raises questions as to whether the doctor who reportedly ordered the service ever saw the beneficiary." The ordering physician did not bill Medicare for treating the beneficiary, such as an office visit any time in 2006 or 2007 up until the day of the ultrasound.
Another clue was the finding of "suspect combinations of ultrasound services billed for the same beneficiary on the same day by the same provider, or specific procedures that are not effective in adults. An example would be duplicative services, such as billing for both a complete abdominal scan and a scan of an individual organ within the abdominal cavity.
"This raises concerns of unnecessary or inappropriate use of services."
A third area of potential overuse was seen in the fact that in some cases, more than five ultrasound services were provided to the same beneficiary on the same day by the same provider," raising "concerns of excessive utilization of services."
A fourth area highlighted beneficiaries who had ultrasound services billed by more than five providers in 2007, raising concerns of "misuse of beneficiaries' Medicare numbers."
The fifth clue was found in missing or invalid data in the claims' fields that identifies the physician who orders the service, raising "questions about whether the service was ordered by a physician treating the beneficiary."
Of the $2 billion paid out for more than 17 million ultrasound services in Medicare ambulatory settings in 2007, providers in just 20 counties received 16% of Medicare spending in this category, or $336 million, despite the fact that the counties have only 6% of the Medicare beneficiaries, Inspector General Daniel R. Levinson wrote.
His report said these 20 counties were in the top 1% of counties for both average allowed charges for ultrasound per Medicare beneficiary, and percentage of beneficiaries who received ultrasound services.
The report focused on billings for the technical component of conducting the ultrasound in ambulatory settings, covered under Part B, rather than the physician' fee for interpreting the image.
Other findings in the report:
- Nearly one in five provider claims for payment nationally "had characteristics that raise concern about whether the claims were appropriate."
- Average per-beneficiary spending on ultrasound in high-use counties was more than three times that for beneficiaries in the rest of the country. Part B spent an average of $171 on ultrasound tests for every beneficiary in the high-use counties compared to $55 in the rest of the country.
- Twice as many beneficiaries received ultrasound services in high-use counties as in the rest of the country.
- Beneficiaries in high-use counties who received ultrasound services received an average of 3.2 services compared to 2.5 services for beneficiaries in the rest of the U.S.
- Certain providers appeared to file a greater number of questionable claims. For example, the report said, "a group of 672 providers each billed 500 or more claims with questionable characteristics. These providers collectively billed over half a million such claims representing over $81 million in Part B charges in 2007."
The report also noted that in high use counties, the ratio of ultrasound providers to beneficiaries was more than three times that for the rest of the country.
While the Inspector General's office did not conduct an investigation of the suspicious ultrasound claims, and said that the findings did not necessarily mean the claims were fraudulent, it nevertheless recommends more forceful efforts to verify that such tests were appropriate.
Shawn Farley, spokesman for the American College of Radiology, says that in addition to any financial incentives to perform these exams many physicians who perform inappropriate ultrasound exams may be simply practicing defensive medicine. Or the patient may be putting pressure on the doctor to perform an exam because he or she saw that a famous person received a certain imaging exam.
To be sure the exam is appropriate, the ACR offers all physicians access to the ACR Appropriateness Criteria, which ranks the most appropriate exams for more than 200 clinical indications, to use in determining which patients should have certain imaging tests, Farley says.
The Inspector General's report suggests that "compared to other types of diagnostic imaging machines, which can cost millions of dollars to acquire and install, ultrasound machines are relatively inexpensive. Providers can buy used machines for under $5,000 and roll them into examining rooms on carts."
Farley says the ACR encourages all providers to seek accreditation to make sure that equipment has been surveyed by a medical physicist to help ensure that the machine is functioning properly and is capturing the best images. ACR also encourages patients to seek out ACR-accredited facilities at which to receive imaging care.