Feds Find Many Docs Are Using Ultrasounds Too Often, Possibly Fraudulently

HealthLeaders Media Staff, July 24, 2009

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."

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