ELECTRODIAGNOSTIC TESTING—QUESTIONABLE BILLING
1. Electrodiagnostic Testing—Questionable Billing
We will review Medicare claims data to identify questionable billing for electrodiagnostic testing. We will also determine the extent to which Medicare utilization rates differ by provider specialty, diagnosis, and geographic area for these services.
Electrodiagnostic testing, which assists in the diagnosis and treatment of nerve or muscle damage, includes the needle electromyogram and the nerve conduction test. Coverage for diagnostic testing is provided by the Social Security act, § 1861(s)(2), and 42 CFR § 410.32.)
The use of electrodiagnostic testing for inappropriate financial gain poses a growing vulnerability to Medicare. (OEI; 04-12-00420; expected issue date: FY 2013; work in progress)
2. Part B Imaging Services—Payments for Practice Expenses
We will review Medicare claims data to identify questionable billing for electrodiagnostic testing. We will also determine the extent to which Medicare utilization rates differ by provider specialty, diagnosis, and geographic area for these services.
For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate. Practice expenses are those such as office rent, wages, and equipment.
Physicians are paid for services pursuant to the Medicare physician fee schedule, which covers the major categories of costs, including the physician professional cost component, malpractice costs, and practice expenses.
(Social Security Act, § 1848(c)(1)(B).) (OAS; W-00-12-35219; W-00-13-35219; various reviews; expected issue date: FY 2013; work in progress and new start)
3. Diagnostic Radiology—Medical Necessity of High-Cost Tests
We will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.
Medicare will not pay for items or services that are not “reasonable and necessary.” (Social Security Act, § 1862 (a)(1)(A).) (OAS; W-00-12-35454; W-00-13-35454; various reviews; expected issue date: FY 2013; work in progress and new start)
4. Laboratory Tests—Billing Characteristics and Questionable Billing in 2010 Dates of Service
We will describe billing characteristics for Part B clinical laboratory tests in 2010. We will also identify questionable billing for Part B clinical laboratory tests in 2010. In 2008, Medicare paid about $7 billion for clinical laboratory services, which represents a 92-percent increase from 1998. Much of the growth in laboratory spending was the result of increased volume of ordered services. Medicare pays only for those laboratory tests that are ordered by a physician or qualified nonphysician practitioner who is HHS OIG Work Plan | FY 2013 Part I: Medicare Part A and Part B treating a beneficiary. (42 CFR § 410.32(a). (OEI; 03-11-00730; expected issue date: FY 2013; work in progress)
