A recent report by the GAO analyzing Medicare Part B claims and spending on advanced imaging services, including magnetic resonance imaging (MRI) and computed tomography (CT), revealed that self-referring providers referred substantially more of these services than did non-self-referring providers. A self-referral occurs when a provider refers a patient to an entity with which the provider or an immediate family member has a financial relationship, including referrals to the physician's own practice for advanced imaging services.
The GAO found that while the number of MRI and CT services increased overall from 2004 to 2010, the number of self-referred services increased much more dramatically by 80 percent over this period. Additionally, expenditures for self-referred MRI services increased approximately 55 percent during this period, while expenditures for non-self-referred MRI services decreased about 8.5 percent. Overall, self-referring physicians referred about two times as many advanced imaging services as providers who did not self-refer, with the largest percentage increase in referrals coming in the first year the provider began self-referring.
The GAO concluded that Medicare spent about $109 million more in 2010 than it would have if self-referring providers had referred MRI and CT services at the same rate as non-self-referring providers of the same specialty and practice size. HHS responded to the report and stated it would consider implementing an approach to insure the appropriateness of advanced imaging services referred by self-referring providers. HHS rejected the GAO's proposal to include a "self-referral flag" on its Part B claims for advanced imaging services because of concerns regarding the administration and accuracy of such a mechanism. HHS also declined to adopt the GAO's recommendation to implement a payment reduction for self-referred advanced imaging services.
The GAO was openly critical of HHS's response to the report and expressed concern that HHS appeared not to recognize the need to monitor the self-referral of potentially unnecessary advanced imaging services. The GAO also is currently reviewing self-referral of anatomic pathology services, intensity-modulated radiation therapy services and physical therapy services. Providers are reminded to review their practice models related to ancillary services to ensure compliance with an available exception to the Stark Law.