Additional imaging service referrals by providers who self-referred cost Medicare approximately $109 million, according to a U.S. Government Accountability Office report.
The report, "Higher Use of Advanced Imaging Services by Providers Who Self-Refer Costing Medicare Millions," examined the rate of imaging referrals among providers who self-referred and those who did not, and the accompanying costs.
Results showed that from 2004 through 2010, the number of self-referred MRI services increased by more than 80 percent, while the number of non-self-referred MRI services increased by only 12 percent.
Overall, self-referring providers referred roughly twice as many imaging services in 2010 as providers who did not self-refer, according to the report. GAO estimates self-referring providers likely made 400,000 more referrals for advanced imaging services in 2010 than they would have if they were not self-referring, resulting in an approximate cost of $109 million to Medicare. Moreover, these additional referrals pose a risk to patient safety due to increased radiation exposure, according to the GAO report.
The differences in referral rates between self-referring and non-self-referring providers remained after accounting for practice size, specialty, geography and patient characteristics, according to the report.
To address the high rate of imaging service referrals among self-referring physicians, GAO made three recommendations to the administrator of CMS:
1. Insert a self-referral flag on its Medicare Part B claims form and require providers to indicate whether the advanced imaging services for which a provider bills Medicare are self-referred or not.
2. Determine and implement a payment reduction for self-referred advanced imaging services to recognize efficiencies when the same provider refers and performs a service.
3. Determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring providers.
While HHS said it would consider the third recommendation, it did not concur with the first two. For the first recommendation, HHS said CMS believes a new checkbox on the claim form would be complex to administer and may not characterize referrals accurately. For the second recommendation, CMS commented that an additional payment reduction may cause providers to refer more services in an effort to maintain their income, according to the report.
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The report, "Higher Use of Advanced Imaging Services by Providers Who Self-Refer Costing Medicare Millions," examined the rate of imaging referrals among providers who self-referred and those who did not, and the accompanying costs.
Results showed that from 2004 through 2010, the number of self-referred MRI services increased by more than 80 percent, while the number of non-self-referred MRI services increased by only 12 percent.
Overall, self-referring providers referred roughly twice as many imaging services in 2010 as providers who did not self-refer, according to the report. GAO estimates self-referring providers likely made 400,000 more referrals for advanced imaging services in 2010 than they would have if they were not self-referring, resulting in an approximate cost of $109 million to Medicare. Moreover, these additional referrals pose a risk to patient safety due to increased radiation exposure, according to the GAO report.
The differences in referral rates between self-referring and non-self-referring providers remained after accounting for practice size, specialty, geography and patient characteristics, according to the report.
To address the high rate of imaging service referrals among self-referring physicians, GAO made three recommendations to the administrator of CMS:
1. Insert a self-referral flag on its Medicare Part B claims form and require providers to indicate whether the advanced imaging services for which a provider bills Medicare are self-referred or not.
2. Determine and implement a payment reduction for self-referred advanced imaging services to recognize efficiencies when the same provider refers and performs a service.
3. Determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring providers.
While HHS said it would consider the third recommendation, it did not concur with the first two. For the first recommendation, HHS said CMS believes a new checkbox on the claim form would be complex to administer and may not characterize referrals accurately. For the second recommendation, CMS commented that an additional payment reduction may cause providers to refer more services in an effort to maintain their income, according to the report.
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