GAO calls for better monitoring of advanced imaging self-referrals


New study results have prompted the Government Accountability Office (GAO) to, in turn, encourage the Centers for Medicare & Medicaid Services to better track and quantify volumes of advanced imagining self-referrals, believing that physicians with more financial stake in the procedure tend to refer the services more frequently. Just like that, a domino effect is again at play.

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“GAO recommends that CMS improve its ability to identify self-referral of advanced imaging services and address increases in these services. The Department of Health and Human Services, which oversees CMS, stated it would consider one recommendation, but did not concur with the others. GAO maintains CMS should monitor these self-referred services and ensure they are appropriate,” a side-bar to the 52 page report reads.

For 2010, the GAO estimates that those physicians more financial immersed in MRI or CT scan orders issued 40,000 more referrals than would have been necessary had no monetary involvement been present. Furthermore, the GAO posits that these additional orders cost Medicare some $109 million that year.

"To the extent that these additional referrals were unnecessary, they pose unacceptable risks for beneficiaries, particularly in the case of CT services, which involve the use of ionizing radiation that has been linked to an increased risk of developing cancer," the study ventured.

[See also: CMS serves up answers to questions on transitions-of-care measure]

GAO analysis pegs the increase in provider referrals for such services as occurring the year following a physicians decision to self-refer, meaning the period after a practice acquired or leased imaging equipment or joined another practice/provider group already versed in the practice of self-referral.

“Providers that began self-referring in 2009—referred to as switchers—increased MRI and CT referrals on average by about 67 percent in 2010 compared to 2008,” the report found. “In the case of MRIs, the average number of referrals switchers made increased from 25.1 in 2008 to 42.0 in 2010. In contrast, the average number of referrals made by providers who remained self-referrers or non-self-referrers declined during this period.”

The GAO report recommended CMS ensure the following actions take place to enhance the self-referral advanced imaging identification and amendment process:

  • 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.
  • Determine and implement a payment reduction for self-referred advanced imaging services to recognize efficiencies when the same provider refers and performs a service.
  • Determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring providers.

“Given the challenges to the long-range fiscal sustainability of Medicare, it is imperative that CMS develop policies to address the effect of self- referral on the utilization of and expenditures for advanced imaging services,” the report concluded.

Find the GAO report in its entirety here.

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