OIG Report Questions IDTF Billings

March 19, 2012

In a Study released March 15, 2012, the Department of Health and Human Services, Office of Inspector General (OIG), reported on what it determined to be questionable billing by Independent Diagnostic Testing Facilities (IDTFs) for claims submitted in 2009. In conducting this study, the OIG analyzed claims among geographic areas, identified as Core Based Statistical Areas (CBSAs). The OIG then identified the 20 CBSAs with the highest average Medicare payments per beneficiary for IDTF services (the "high-utilization CBSAs"), compared IDTF billing patterns in high-utilization CBSAs to billing patterns in other CBSAs, identified IDTF claims with questionable characteristics, and compared the prevalence of IDTF claims with questionable characteristics in high-utilization CBSAs to the prevalence of such claims in all other CBSAs. OIG did not review the claims to determine whether the services were provided, whether any claims were medically necessary, or whether claims were coded correctly.

The findings of this Study include the following:

1. The 20 high-utilization CBSAs accounted for 11% of Medicare Part B payments for IDTF services, despite only having 2% of the total population of Medicare beneficiaries;
2. Almost 4 times more beneficiaries in high-utilization CBSAs received IDTF services than beneficiaries in other CBSAs;
3. On average, beneficiaries in high-utilization CBSAs received more IDTF services than beneficiaries in all other CBSAs;
4. The average Medicare payment per beneficiary who received an IDTF service in high-utilization CBSAs was almost 25 percent higher than in all other CBSAs;
5. 90% of IDTF services provided in high-utilization CBSAs were provided by 9% of IDTFs;
6. 71% of IDTFs providing services to beneficiaries in high-utilization CBSAs were in the Miami-Fort Lauderdale-Pompano Beach, Florida, CBSA;
7. High-utilization CBSAs had twice as many IDTF claims with at least two questionable characteristics as all other CBSAs (the OIG identified the following 3 characteristics as questionable: (1) a beneficiary being linked to 4 or more IDTFs; (2) IDTF claims that lacked corresponding claims by the referring physicians; and (3) IDTF claims for which the diagnosis categories were not the same as those on any other provider claims for those beneficiaries).

As a result of the Study, the OIG recommended that CMS monitor IDTF claims for questionable characteristics, review the claims of IDTFs which are found to have a high rate of questionable billing characteristics before payment to ensure that they are appropriate, and to assess whether to impose a temporary moratorium on new IDTF enrollments in CBSAs with high concentrations of IDTFs. CMS concurred in the OIG recommendations and indicated that IDTFs remain a key current focus of CMS and will continue to remain a key focus going forward.

This Study and CMS' comments on the Study show the continued focus by the government on IDTF facilities. Due to the continued focus of the government on IDTFs, any IDTF must, now more than ever, ensure full compliance with Medicare standards.

For assistance with or for more information Independent Diagnostic Testing Facilities or Medicare and Medicaid programs please contact Adrienne Dresevic, Esq. or Carey Kalmowitz, Esq. at (212) 734-0128 or (248) 996-8510. More information may also be obtained at the HLP website.