Medicare Dialysis Patients: Widely Varying Lab Test Rates Suggest Need for Greater HCFA Scrutiny
HEHS-97-202
Published: Sep 26, 1997. Publicly Released: Oct 31, 1997.
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Highlights
Pursuant to a congressional request, GAO examined the anomalous patterns of test rates among dialysis patients, focusing on: (1) the extent to which the rates for providing laboratory tests to Medicare patients varied among dialysis facilities; (2) the appropriateness of these rates; (3) reasons for the variation; and (4) the adequacy of the reviews that the Health Care Financing Administration (HCFA), the agency administering Medicare, performs to examine laboratory test claims.
Recommendations
Matter for Congressional Consideration
| Matter | Status | Comments |
|---|---|---|
| The Congress may wish to consider making the ordering physician liable for the recovery of payments made to laboratories when the physician continues to order tests that are not medically necessary or are provided too frequently, after having been notified of a pattern of such inappropriately high testing rates. |
Closed – Not Implemented
|
The Committee indicated that it has no plans to pursue this recommendation. |
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Health Care Financing Administration | To assist contractors in their efforts to determine the appropriateness of laboratory tests ordered for Medicare dialysis patients, the HCFA Administrator should profile physicians ordering laboratory tests for dialysis patients and notify the contractors of the providers whose test order rates are aberrant. The Administrator should instruct the contractors to review these cases and carefully scrutinize ordering physicians who order too many or too few tests. |
Closed – Implemented
In response to GAO's recommendation, on June 30,1999, HCFA directed its contractors, beginning in fiscal year 2000, to refine their data analysis approaches, methods and software to help identify overutilization and abusive billing practices. The directive suggests that the contractors consider reviewing utilization data based upon the ordering or referring physician, but does not make such analyses mandatory. As a result, the directive, while emphasizing the need for contractors to make greater use of available data to identify overutilization, does not require physician profiling as suggested in GAO's recommendation.
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Topics
Comparative analysisDisease detection or diagnosisHealth care cost controlHealth care servicesMedical examinationsMedical expense claimsMedicarePatient care servicesUrologic diseasesDialysis