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

Cheryl Clark, for HealthLeaders Media , July 24, 2009

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.

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