Medicare paid a total of $38 million in 2008 for erroneous claims for the interpretation of CT, MRI, and x-ray studies performed at hospital emergency departments, according to a report posted this week by the U.S. Department of Health and Human Services' (HHS) Office of Inspector General (OIG).
That year, Medicare paid invalid claims of $29 million for CT and MRI studies, or 19% of all claims for the two modalities in the emergency setting, OIG has found. Medicare paid $9 million for invalid x-ray studies, or 14% of the total for emergency x-ray imaging. The claims were erroneous because they had insufficient documentation, or physicians' orders didn't accompany claims, according to OIG.
For 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. The audit consisted of random samples of 220 CT and MRI claims and 220 x-ray claims.
The review determined the following:
- Physicians' orders were not present in medical record documentation for 12% of CT and MRI claims, amounting to nearly $18 million in erroneous payments.
- Physicians' orders were not present in medical record documentation for 9% of x-ray claims, amounting to $5 million in erroneous payments.
- 69% of interpretation and reports for CT and MRI and 71% of interpretation and reports for x-ray exams did not follow practice guidelines.
In addition, Medicare 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, the OIG said. As for CT and MRI, OIG found that Medicare paid $19 million for interpretation and reports of exams performed after beneficiaries had been discharged.
Get with the program
In light of this data, OIG made three recommendations to the U.S. Centers for Medicare and Medicaid Services (CMS):
- Educate providers on the requirement to maintain documentation on submitted claims.
- Implement a uniform policy for single and multiple claims for interpretation and reports of diagnostic radiology services to require that claimed services be at the time of the emergency department visit, or identify circumstances in which exams done after a patient is discharged may contribute to the diagnosis and treatment of beneficiaries in hospital outpatient emergency departments.
- Take appropriate action on the erroneously allowed claims identified in the report sample.
In a written response, CMS agreed with OIG's first and third recommendations, but not the second. The agency plans to issue an educational article to healthcare providers to emphasize that documentation requirements will be enforced, and it will take appropriate action regarding the erroneous claims once it has received files from OIG.
