Print Article

November 21, 2012
The essential resource for your practice
Volume XXI, Number 11
Table of Contents

  

GAO Releases Report on CT, MRI Self-Referral

In October 2012, the Government Accountability Office (GAO) released a new Congressionally mandated report, titled Higher Use of Advanced Imaging Services by Providers Who Self-Refer Costing Medicare Millions. The report, which examines physicians’ use of CT and magnetic resonance imaging (MRI), concludes that physicians who self-refer these services do so more often than those who do not self-refer. And, although the report does not specifically address urology (instead taking a generalized approach), it does include usage information for the specialty, indicating that urology is second only behind radiation oncology in terms of overall change in CT self-referral rate from 2004 to 2010 (a 23.4 percent increase).

Other highlights of the report include:

  • Data reviewed for the report indicated that patients of self-referring doctors were no older or sicker than those of doctors who did not self-refer
  • The GAO acknowledges the efficiency of having certain components performed by a single provider (e.g., reviewing histories) and acknowledges the multiple procedure payment reduction, but does not discuss the efficiencies/benefits to patients of in-office imaging
  • The GAO makes the following three recommendations for executive action by CMS:
  • 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; and
  • Determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring providers.
  • The U.S. Department of Health and Human Services (HHS), in its comments on the report, agrees with only one of the GAO’s recommendations in terms of identifying trends in self-referral over time so that appropriate ‘intervention’ can take place to identify/prevent unnecessary use of MRI and CT. HHS asserts that it would be too cumbersome to flag claims for self-referred services.

Following the report’s issuance, Representatives Pete Stark (D-CA), Sandy Levin (D-MI) and Henry Waxman (D-CA), along with Sens. Max Baucus (D-MT) and Chuck Grassley (R-IA), issued a press release calling for Congress to seriously consider the role that self-referral is playing in driving up health care costs. “It should serve as a wakeup call to Congress that this is an arena where we can’t afford to sit idly by and allow providers to continue these practices,” Rep. Stark said in the release. “…Once again, we’re seeing how money drives behavior. We need to step in to stop these abusive self-referral arrangements now.”

The issue of urologists’ self-referral has been ongoing for multiple years, with intensity modulated radiation therapy , computed tomography (CT) and pathology becoming targets for attack by lawmakers and regulators. This situation is exacerbated by other competing specialty groups (e.g., College of American Pathologists, American Society for Radiology Oncology, American College of Radiology, etc.), who may disagree with urology’s position and others that engage in a turf war to maintain market share. While the primary impact of the GAO report to urologists remains to be seen, it will be necessary to wait to determine what Congressional action may be taken in response. The AUA will be vigilant moving forward into the next Congressional session and remain positioned to respond proactively and reactively as necessary with lawmakers as they broach the issue.