The Office of Inspector General (OIG) recently issued a report¹ examining the use of magnetic resonance imaging (MRI) services under the Medicare Physician Fee Schedule. Specifically, the OIG sought to determine if there was a relationship between utilization levels of services and how the services are provided.²

Currently, Medicare has two types of payments for imaging: the technical component involves reimbursement for taking the image, and the professional component which pays the physician who reads and interprets the image. Often times there are separate providers for each part, but Medicare can issue one global payment to one of the providers with the expectation that the provider will redirect the funds as appropriate. Additionally, Medicare allows one provider to purchase one or both components of MRI services from other providers and bill Medicare, even though that provider did not actually perform either service.³

In addition to the two possible payment parties for MRI services, several other people may be involved in actually providing the MRI service, including physicians, technicians, radiologists, and nurses. When several people are involved in performance of one MRI scan, they may be connected to one another through a medical practice or other professional relationship. A medical practice relationship is defined as one or more parties “sharing a membership in a medical practice or when one party is a member of the other,” whereas a business relationship is defined as one or more parties sharing a common business interest (e.g., shared investments).  While all MRI services must abide with federal Fraud and Abuse laws by avoiding physician self-referrals and kickbacks; however, because Medicare billing does not identify all involved parties, the OIG was concerned that billing claims may not show evidence of medical practice and business relationships.⁴

The OIG report examined the technical component of billing claims to determine if a relationship existed between utilization and how services were provided for MRI services.  Data was for obtained for over 2.6 million Medicare claims from Medicare’s National Claims History (NCH) database and did not evaluate medical necessity or appropriateness of provider relationships. Data was split into three categories: doctors whose charges placed them in the 95^th percentile of all doctors who ordered MRIs; doctors whose orders for advanced services placed them in the 95^th percentile of all doctors who ordered MRIs; and, doctors who did not fit into the first two categories.⁵  This data was supplemented with surveys from billers as well as business registration data for each physician. From this information, the study identified relationships between the parties involved in treatment for MRI services.⁶

Upon completion of the study, data were analyzed in two groups: services ordered by high users of MRIs and services ordered by connected physicians.⁷  Results of the study indicated that, for MRI use under the Medicare Physician fee schedule, most providers were consistent in ordering of tests, providing of tests, and billing for the tests.⁸  The study also found that, 85% of the time, the performer of the service and the payee for the service were the same.⁹

Additionally, the study concluded that approximately two-thirds of the services were ordered by physicians who fell into one of four specialties: internal medicine, orthopedic surgery, family practice, and neurology.  When the researchers examined this data among the group of high-user physicians, they found that the majority of their services were also ordered by the same four specialties.  However, of these four specialties, neurologists and orthopedic surgeons accounted for 51% of MRI services, while they only accounted for 20% of other services.¹⁰

The OIG did find that one quarter of the MRI  services were “connected services” that were associated with high use. The study defined connected services as a service in which the party that ordered the service was connected in some way to the party who provided the technical component of the service. The OIG further examined the concept of connected services and found that orthopedic surgeons were more likely to order connected services because they accounted for 28% of connected services, compared to 15% for all other services.  Furthermore, the physicians in the high-user group accounted for 55% of connected services, compared to the ordering of 33% of non-connected services.  Additionally, results indicated that multi-specialty groups performed half of all connected services.  Finally, “Connected services were more likely than other services to have been billed only as the technical component; to have had payment reassigned; and to have been billed through a provider other than a radiologist.”¹¹

Overall, results indicated a high number of connected services when billing for MRI services. While the reported findings of the study did not indicate and intent to seek to identify inappropriate relationships among physicians, it does highlight the need for all physicians who bill Medicare to be aware of potential conflicts of interest.  Additionally, the report demonstrated the limited transparency of MRI use and reimbursement.  CMS has supported the OIG’s finding of the need for more transparency of this data, and has outlined several steps to reduce potential overutilization of MRI services and indicated a need for further examination of relationships among parties who bill for and parties who perform MRI services.¹