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Highlights

Pursuant to a congressional request, GAO compared physicians' referral rates for diagnostic imaging services, focusing on: (1) referrals by physicians with a financial interest in joint-venture imaging service facilities; and (2) whether the Department of Health and Human Services' (HHS) procedures and policies are effective in monitoring and identifying abusive self-referral practices.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services The Secretary of Health and Human Services should direct the Administrator, HCFA, to develop the procedures and policy guidance needed for the Medicare contractors to closely monitor Medicare imaging referral patterns and utilization rates.
Closed - Implemented
On January 9, 1998, HCFA published a "Proposed Rule on Physicians' Referrals to Health Care Entities With Which They Have Financial Relationships" (Regulation 1998. Identification Number 0938-AG80). Following review of comments on the proposed rule, HCFA published a Final Rule (RIN 0938-1809 FC) on January 4, 2001, incorporating substantial changes. A comment period on the final rule concluded on June 5, 2001, and the rule became effective in 2002. CMS has developed guidance for its contractors and the provider community to help providers comply with the rules. CMS plans a second phase of rulemaking on this issue, with additional guidance materials to follow.
Department of Health and Human Services The Secretary of Health and Human Services should direct the Administrator, HCFA, to develop the procedures and policy guidance needed for the Medicare contractors to ensure compliance with the provisions of the self-referral ban.
Closed - Implemented
The Final Rule, "Physician Referrals to Health Care Entities With Which They Have Financial Relationships" (RIN 0938-1809-FC) was issued on January 4, 2001, with a comment period, to be effective in 2002. This is considered to be the Phase I final rule--further rulemaking is anticipated. To date, the agency has provided policy guidance on the rules available on the web, and has issued two advisory opinions concerning whether specific arrangements violate the self-referral ban. According to the final rule, the agency intends to provide further educational materials after Phase II of the final rule is published.
Department of Health and Human Services The Secretary of Health and Human Services should direct the Administrator, HCFA, to develop the procedures and policy guidance needed for the Medicare contractors to identify any overutilization of imaging services ordered and provided from within physician practice settings.
Closed - Implemented
The Final Rule, "Physician Referrals to Health Care Entities With Which They Have Financial Relationships" (RIN 0938-1809-FC) was issued on January 4, 2001, with a comment period, and was effective in 2002. Since then, CMS has published educational materials and advisory opinions to help guide contractors and physicians.
Department of Health and Human Services The Secretary of Health and Human Services should systematically review imaging utilization information developed by HCFA and use the authority provided under the Omnibus Budget Reconciliation Act of 1993 to develop any additional regulations needed to reduce overutilization through abusive self-referral practices.
Closed - Not Implemented
The Final Rule, "Physician Referrals to Health Care Entities With Which They Have Financial Relationships" (RIN 0938-1809-FC) was issued on January 4, 2001, with a comment period, and was effective in 2002. CMS is planning a second phase of final rulemaking. Since this recommendation was made, CMS has developed better capacity to analyze claims in certain jurisdictions to identify problem billing practices. This recommendation anticipates that CMS will obtain data on referral patterns at some point in the future, and the Secretary will analyze the data to determine if further regulation is needed. Because of the nature of the rulemaking on the complex issues of self referral, CMS may not be able to fully implement the recommendation for several more years.

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