OIG cautions CMS about ultrasound overuse
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The OIG said it undertook the analysis of Medicare Part B claims for ultrasound services to describe utilization of ultrasound services in counties with high use of ultrasound and compare it to utilization in other counties; and identify claims with "questionable characteristics."
In 2007, Medicare Part B covered about 17 million ultrasound services in ambulatory settings at a cost of over $2 billion. The report noted that previous "OIG work has raised concerns about the growth in other types of imaging covered under Part B and found that high geographic concentrations of providers or services may indicate weaknesses in Medicare's program safeguards."
They analysts used 2007 Medicare Part B claims data to identify 20 counties that were in the top 1 percent of counties for both average allowed charges for ultrasound per Medicare beneficiary and percentage of beneficiaries who received ultrasound services. Nine of these counties were in Florida; five in New York; three in New Jersey; and one each in Alabama, Michigan and Texas.
The office analyzed the claims data to compare use of ultrasound in the high-use counties to that in all other counties. They also examined claims for the presence of a limited set of questionable characteristics, such as suspect combinations of procedures or lack of a service claim from the doctor who ordered the service. However, the office did not assess the medical necessity of services.
The OIG found 20 high-use counties accounted for 16 percent of Part B spending on ultrasound despite having only 6 percent of Medicare beneficiaries in 2007. The 20 high-use counties accounted for $336 million of the $2.1 billion in Part B spending on ultrasound services. They found that average per-beneficiary spending on ultrasound in high-use counties was more than three times that for beneficiaries in the rest of the country. Twice as many beneficiaries received ultrasound services in high-use counties as in the rest of the country. When these beneficiaries received ultrasound services, they received more services than other beneficiaries receiving ultrasound services in the rest of the country. Finally, the ratio of ultrasound providers to beneficiaries in high-use counties was more than three times that for the rest of the country.
They also found that nearly one in five ultrasound claims nationwide had characteristics that "raise concerns about whether the claims were appropriate." The 3.2 million claims represent $403 million in Part B charges. The overall rate of ultrasound claims exhibiting one or more questionable characteristics was the same in high-use counties as it was in all other counties. Lack of a service claim by the ordering doctor for treating the beneficiary was the most common of the questionable characteristics. The other characteristics were far less common but more prevalent in high-use counties than other counties.
Finally, OIG found that certain providers billed for a large number of ultrasound claims with questionable characteristics. 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.
Based on their findings, the OIG recommended that the Centers for Medicare & Medicaid Services (CMS):
- Monitor ultrasound claims data to detect questionable claims, which would "reduce Medicare's vulnerability to questionable claims for ultrasound services by enabling CMS to develop claims-processing edits that flag them for review prior to payment."
- Take action when providers bill for high numbers of questionable claims for ultrasound services. When its monitoring identifies providers that bill for large numbers of questionable claims, CMS should review their claims to ensure that they are legitimate prior to payment. If CMS determines that such providers submit fraudulent claims, it should take steps to revoke their Medicare billing numbers.
In its written comments to this report, the OIG said that CMS concurred with both its recommendations and described actions it would take to address them.