October 19, 2009
Ultrasound Overutilization — OIG Report Questions Exam Appropriateness
By Beth W. Orenstein
Vol. 10 No. 17 P. 10
Twenty counties with 6% of Medicare beneficiaries accounted for 16% of Part B spending in 2007.
Most of the ongoing—and sometimes heated—debate over imaging overutilization has focused on CT, MRI, and PET studies—until now. In July, the Office of Inspector General (OIG) released the report “Medicare Part B Billing for Ultrasound,” which cast a suspicious eye on ultrasound exams.
In 2007, Medicare spent more than $2 billion for about 17 million ultrasound services in doctors’ offices, independent diagnostic testing facilities, and other settings covered under Medicare Part B. The OIG report looked at those ultrasound exams and found that nearly one in five had characteristics that raised concerns about whether the claims were appropriate. It also found that 20 counties (nine of which were in Florida) accounted for 16% ($336 million) of Part B spending on ultrasound despite having only 6% of Medicare beneficiaries.
Does the OIG report signal that government and private payer watchdogs will be turning their attention to ultrasound? Those representing the sonography profession aren’t sure of the report’s implications. However, they don’t believe that overutilization is a widespread problem in sonography. They acknowledge that some overutilization occurs in all diagnostic imaging modalities but believe that safeguards already in place, especially in sonography, prevent abuse most of the time.
“In the past, we’ve been on record as saying there is a certain amount of unnecessary utilization going on out there in all modalities,” says Shawn Farley, an ACR spokesperson. However, as with any imaging modality, physicians need to be sure the exams they order are appropriate and necessary, and, most often, they do, according to Farley.
Harvey L. Nisenbaum, MD, FACR, FAIUM, FSRU, chairman of the medical imaging department at Penn Presbyterian Medical Center in Philadelphia and president of the American Institute of Ultrasound in Medicine (AIUM), says the OIG’s report raises some concerns about specific instances and they should be investigated further, but he doesn’t believe the abuse is rampant. In fact, Nisenbaum says, physicians should think more about using sonography rather than CT if they can because sonography doesn’t expose patients to ionizing radiation.
Shannon Boswell, BS, RDMS, RDCS, RVT, FSDMS, president of the Society of Diagnostic Medical Sonography (SDMS), and SDMS Vice President Joy Guthrie, DHSc, RDMS, RDCS, RVT, ROUB, also agree that while the OIG report found some questionable claims that are disconcerting, most healthcare providers can catch unnecessary scans when they are ordered.
Farley cites several reasons for the increase in diagnostic imaging services, and he says they apply to all modalities, not just sonography. “One is self-referral and the financial incentives to do more imaging using their own machines. The second is fear of litigation. Physicians are concerned that at some later date, they are going to be sued and some attorney is going to come back and ask, ‘Why didn’t you do this imaging exam?’ A third reason is patient demand. A guy hurts his shoulder playing football in his backyard. The physician wants to prescribe anti-inflammatories and see how he does, but the patient says, ‘I see where Peyton Manning, or some other famous athlete, had an MRI when he hurt his shoulder. Why aren’t you doing that for me?’”
Farley says the ACR has helped address the utilization issue for all modalities by making its appropriateness criteria for more than 215 clinical indications available to all physicians free of charge. The criteria outline which modality, if any, would be the most appropriate for the symptoms a patient presents with and which would be second best, etc. “This is something we actively promote to all physician groups as well,” Farley says.
The ACR also encourages providers to seek accreditation to make sure the equipment they are using is functioning properly and capturing the best images possible the first time, Farley says. ACR accreditation ensures that the equipment has been surveyed by a medical physicist and is properly calibrated, he says. If the images are of high quality the first time, it cuts down on the number of repeat exams, and repeat exams could be seen by payers as overutilization in some cases, he says.
Nisenbaum says the instances of abuse that the OIG report flagged seem legitimate. For example, he says, the study cited an instance where Medicare was billed for a complete abdominal study and a limited evaluation of organs that were included in the complete study. Questions also arose about a patient who had five ultrasound studies in one day and cases where physicians billed for sonograms but not for having seen the patient.
“If a patient has five studies in one day, that raises some questions,” Nisenbaum says. “Also, if you have a study requested by a physician and that physician doesn’t bill for having seen the patient, it could be they are abusing the system.” The report said that ultrasound claims without prior service claims raise questions because they suggest the doctor who ordered the service may not have seen the beneficiary.
Of the 20 counties with cases of suspected abuse, nine were in Florida, five in New York, three in New Jersey, and one each in Alabama, Michigan, and Texas. “It’s possible,” Farley says, “that the demographics had an effect on usage” in Florida due to the state’s aging population.
The report found that the average per-beneficiary spending on ultrasound exams in those 20 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 those beneficiaries received ultrasound services, they received more services than other beneficiaries getting ultrasound services in the rest of the country. Finally, the ultrasound providers-to-beneficiaries ratio in high-use counties was more than three times that for the rest of the country, according to the report.
However, Nisenbaum says, without further investigation, it’s hard to tell whether the instances that were cited in the report are commonplace or outliers. “I think the OIG did a good job on this. They did a fair analysis of looking at the problem areas and raising questions. The next thing is to go to the places where there were alleged abuses and find out more. That’s the first place you would start,” he says.
It seems, Nisenbaum adds, that procedures could easily be set in place that would capture such abuses and Medicare could refuse to pay. “There’s abuse,” he says, “but you have certain requirements in any bill that you can set in place. If there are problems, there are ways to flag them. It’s a matter of putting procedures in place.”
Boswell, who is also the ultrasound manager and radiology performance improvement manager at Virginia Mason Medical Center in Seattle, says her department has never done five exams on one patient at one time. “We’ve done three occasionally and two frequently but never to milk the system. It’s to help answer specific questions raised in the patient’s chart,” she says.
Boswell says that in her area, if a physician were to request a study that overlaps with one that had just been done, the sonographers would question whether it was really necessary. There could be a legitimate reason for the second study to be ordered—perhaps as a follow-up or for determining whether a patient’s condition has changed, she says. In most cases, the second exam would be a limited study. Often, she says, when the situation is called to the provider’s attention, the physician says never mind unless he or she had a reason for wanting a repeat exam. Calling questionable studies to the attention of the providers “is what we do in our lab,” she says, “and I’m sure many other labs do the same thing.”
Boswell’s lab also requires written or electronic documentation of all exam orders. “That’s how we make sure we avoid problems. When orders are verbal, you might have misunderstood what the doctor said,” she says.
“[Sonographers] need to be the ones to make sure the exam is necessary because we know what to look for and if a clinical question has already been answered. If we have questions or concerns, then we should loop in the providers,” she adds.
Boswell also says that while the utilization of sonography is on the rise, it could be cost-effective and safer for some patients. As a study in a recent issue of the Journal of Diagnostic Medical Sonography points out, sonography’s accuracy and cost-effectiveness in various applications have led to its widespread adoption and use, she notes. According to the study, “The utilization of ultrasound compared to the use of alternative imaging methods leads to increased cost-efficiency in the diagnosis and management of patients.” The study also says that continued research and evaluation are required to provide optimization of patient care through analysis of cost, efficiency, experience, accuracy, disease states, and patient outcomes.
Guthrie, who is also the ultrasound supervisor/technical director of the Community Regional Medical Center and program director for the Merced College Diagnostic Medical Sonography Program in California, agrees that sonographers should prudently check patients’ records to be sure they haven’t recently undergone the same exam. “If we do that and we find that the patient had the same exam within the same week we can ask the physician: ‘This was just done. Are you sure you want it again?’” There are legitimate reasons to repeat a sonogram, Guthrie says, “especially if the patient has an acute illness and you need to see if things are changing.” But in other cases, the order could be a mistake and rather than repeat the exam, if it’s brought to someone’s attention, it may be avoided, she adds.
The OIG’s report pointed out that sonography is different from other types of diagnostic imaging because ultrasound machines are relatively inexpensive compared with MR or CT scanners. Also, ultrasound equipment is becoming more portable and more affordable. Physicians can buy a lightweight machine for under $5,000 and roll it on a cart into a patient’s room, the report noted.
Given its findings, the OIG has made two recommendations that it believes would reduce Medicare’s vulnerability to questionable sonography claims. One is for the Centers for Medicare & Medicaid Services (CMS) to develop claims processing procedures that flag questionable claims prior to payment. The other is to take action when providers bill for high numbers of questionable claims for ultrasound services. Should the CMS find that some providers submit fraudulent claims, it should take steps to revoke their Medicare billing numbers.
The CMS has concurred with both recommendations and said it would share the report’s findings with the Medicare Administrative Contractors for potential additional prepay edits and prepay medical review.
— Beth W. Orenstein is a freelance writer based in Northampton, Pa. She is a frequent contributor to Radiology Today.