EXECUTIVE SUMMARY: QUESTIONABLE BILLING FOR MEDICARE INDEPENDENT DIAGNOSTIC TESTING FACILITY SERVICES
WHY WE DID THIS STUDY
Independent Diagnostic Testing Facilities (IDTF), a type of Medicare provider, offer diagnostic services and are independent of physicians’ offices or hospitals. IDTF services have historically been vulnerable to abuse. In 1997, the Office of Inspector General found that 20 percent of IDTFs were not at the locations on file with the Centers for Medicare & Medicaid Services (CMS). In 2007, CMS reported that in Los Angeles, it had denied $163 million in IDTF charges and terminated Medicare billing privileges for 83 IDTFs.
HOW WE DID THIS STUDY
To describe IDTF billing patterns and identify questionable IDTF claims, we conducted a four-part review of such claims among geographic areas—specifically, Core Based Statistical Areas (CBSA). Based on an analysis of all Medicare Part B IDTF claims from 2009, we
(1) identified the top 20 CBSAs with the highest average Medicare payments per beneficiary for IDTF services, terming these “high-utilization CBSAs”; (2) compared IDTF billing patterns in high-utilization CBSAs to such billing patterns in all other CBSAs nationally; (3) identified IDTF claims with questionable characteristics; and (4) compared the prevalence of IDTF claims with questionable characteristics in high-utilization CBSAs to the prevalence of such claims in all other CBSAs.
WHAT WE FOUND
Twenty high-utilization CBSAs accounted for 10.5 percent of Medicare Part B payments for IDTF services despite having only 2.2 percent of the total population of beneficiaries. Almost four times more beneficiaries in high-utilization CBSAs received IDTF services than beneficiaries in all other CBSAs. Nine percent of the IDTFs that served beneficiaries in high-utilization CBSAs provided 90.1 percent of IDTF services. Additionally, high-utilization CBSAs had twice as many claims with at least two questionable characteristics as all other CBSAs.
WHAT WE RECOMMEND
We recommend that CMS: (1) monitor IDTF claims for questionable characteristics, (2) take appropriate action when IDTFs submit a high number of questionable claims, and (3) assess whether to impose a temporary moratorium on new IDTF enrollments in CBSAs with high concentrations of IDTFs. CMS concurred with all of our recommendations.