Medicare Overspent On Emergency Imaging

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imageMedicare spent too much money on imaging in 2008, paying a total of $38 million in erroneous claims for the interpretation of CT, MRI, and x-ray studies performed at hospital emergency departments, says a report issued by the U.S. Department of Health and Human Services' (HHS) Office of Inspector General (OIG).

Invalid CT and MRI study claims paid by Medicare that year totaled $29 million, or 19% of all claims for the two modalities in the emergency setting, OIG has discovered. Medicare also paid $9 million for invalid X-ray studies, or 14% of the total for emergency X-ray imaging. The claims were deemed erroneous because they were not accompanied by sufficient documentation or physicians' orders, or because both of these elements were missing, according to OIG.

To conduct its review, OIG identified 9.6 million Medicare claims totaling $215 million for interpretation and reports of diagnostic radiology services for beneficiaries in hospital outpatient emergency departments. An audit group comprised random samples of 220 CT and MRI claims and 220 X-ray claims.

The review determined that physicians' orders were not present in medical record documentation for 12% of CT and MRI claims, or a total of nearly $18 million in erroneous payments. Physicians’ orders were found to be missing from medical record documentation for 9% of X-ray claims, or $5 million in erroneous payments. Moreover, practice guidelines were not followed for a whopping 69% of interpretation and reports for CT and MRI and for 71% of interpretation and reports for x-ray exams.

In addition, OIG said, Medicare was discovered to have paid more than $10 million, or 16% of claims, for x-ray exams that may not have contributed to the patients' diagnoses and treatments because they were performed after patients had left the hospital outpatient emergency department. As for CT and MRI, OIG found that Medicare had paid $19 million for interpretation and reports of exams performed after beneficiaries had been discharged.

Given this data, OIG recommended that CMS educate providers on the requirement to maintain documentation on submitted claims, as well as implement a uniform policy for single and multiple claims for interpretation and reports of diagnostic radiology services. OIG also advised CMS to require that claimed services be at the time of the emergency department visit, or to identify circumstances in which exams completed after a patient is discharged may contribute to the diagnosis and treatment of beneficiaries in hospital outpatient emergency departments. A third recommendation stipulated that CMS shoul take appropriate action on the erroneously allowed claims identified in the report sample.

In a written response, CMS expressed agreement with OIG's recommendations regarding provider education and erroneously allowed claims, but rejected the advice pertaining to the timing of claimed services. The agency plans to issue an educational article to healthcare providers to emphasize that documentation requirements will be enforced, and that it will take appropriate action regarding the erroneous claims once it has received files from OIG.