Now, the OIG Takes Aim

In its annual work plan for 2010,1 published October 1, the OIG has indicated more than a passing interest in the specialty of radiology, announcing no less than four imaging-specific initiatives that it intends to pursue in 2010. Two of the agenda items fall into the milder category of inquiries and are unlikely to produce hordes of inspectors descending upon your offices: an audit of radiology practice expenses (including the equipment-utilization rate) and of contemporaneous interpretations of emergency-department studies, prompted in part by the $207 million that Medicare paid emergency-department physicians in 2007. This issue has appeared in and disappeared from the plan over the past 10 years, but has never resulted in a report. A third initiative is a review of services and billing patterns in geographic areas with high densities of IDTFs, a follow-up to the OIG’s 2006 study that found numerous instances of noncompliance and a suspected $71 million in false claims. The 2006 report initiated a set of rigorous new standards for IDTFs. The fourth item, however, represents a potentially more serious action undertaken by the OIG’s Office of Evaluations and Inspections. The OIG plans to investigate how well IDTFs are hewing to the 14 Medicare enrollment standards, including compliance with all federal and state licensure requirements, providing complete and accurate information on enrollment applications, and having technical staff on duty with the appropriate credentials. If properly undertaken, the first two studies could provide support to a much-beleaguered specialty on both sides of the Medicare Part B equation. The third and fourth potentially could saddle a heavily regulated segment of imaging providers in the most competitive markets in the country with further compliance costs. Whether the OIG will act on these items and where it is headed are hard to pinpoint, according to Thomas Hoffman, JD, ACR assistant general counsel. “If the OIG comes out with a report that questions the validity of CMS’ 90% equipment-utilization–rate assumption, and finds that there is a statistical basis to have it much lower, then that is good news for radiology,” Hoffman says, “so it could positively affect the course of payment policy on the Part B front.” Nonetheless, the soonest that the OIG could issue a report is 2011, so the study will have no bearing on the change in the equipment-utilization–rate assumption in the proposed 2010 Medicare Physician Fee Schedule. Hoffman advises all to proceed with caution. “Every year’s work plan bears some room for jurisprudence,” Hoffman says. “The ACR always advises its members to look at their clinical and financial relationships very carefully, confer with their lawyers and business professionals, and know that the government is watching. It has an army of investigators, auditors, and inspectors out there. Influential people listen to the OIG, particularly those who pay the bills.” Overlooking the Obvious With Congress, CMS, the Medicare Payment Advisory Commission, and the OIG gunning for imaging, a pack psychology appears to have overtaken Washington, as if imaging cuts were the answer to Medicare’s money problems. Nonetheless, self-referral remains sacrosanct among lawmakers (and the AMA), even though a mounting body of literature supports the contention that technology ownership by referrers leads to inappropriate utilization. Reportedly, so many urologists in the Long Island area have installed linear accelerators that local hospitals can no longer attract enough referrals to maintain seed-implantation programs. Since the cost of radiation treatment exceeds seed-implant treatment by a factor of nearly 10, this development could ring up some greater-than-necessary charges. In a recent report from the New England Healthcare Institute (NEHI),2 imaging overutilization did not even make the list of six key opportunities to eliminate waste without affecting quality. The authors began with the premise that waste represents a significant amount of the $2.3 trillion spent on health care in 2007, with many experts believing that a third of total spending could be eliminated without a negative impact on quality. The authors arrived at six opportunities, each with a minimum potential annual savings of at least $1 billion, beginning with unexplained variation in the intensity of medical and surgical services, including (but certainly not limited to): end-of-life care, overuse of coronary artery bypass surgery, and overuse of percutaneous coronary procedures (a potential $600 billion savings). The remaining five were drug misuse and treatments, overuse of nonurgent emergency-department care, underuse of generic antihypertensives and controller medicines in pediatric asthma, and overuse of antibiotics for respiratory infections. Five systemic issues at the root of this $680.2 billion in waste were identified as lack of compliance with clinical guidelines, variation in the intensity of clinical care, limited adoption of IT, underuse of cost-effective diagnostic tests, and failure of the primary care system to meet access needs. Apparently, the NEHI is suggesting that we need more (appropriate and cost-effective) imaging, not less. Why haven’t any of the health care geniuses in Washington looked at limiting self-referral as a way to cut imaging costs? Why not build a waste-management program around the cost-effective use of appropriate diagnostic tests? Cheryl Proval, Editor cproval@imagingbiz.com