Self-referral occurs when a provider refers patients to entities in which the provider or the provider's family members have a financial interest. Rising Medicare expenditures for PT services have long been of concern, and questions have been raised about the role of self-referral in this growth. This book examines trends in the number of and expenditures for self-referred and non-self-referred Medicare PT services and how provision of these services differs among providers on the basis of whether they self-refer. It also discusses similar trends in cancer treatments, anatomic pathology services, and advanced imaging services.A\Chapter 1 - Rising Medicare expenditures for PT services have long been of concern, and questions have been raised about the role of self-referral in this growth. Self-referral occurs when a provider refers patients to entities in which the provider or the provider's family members have a financial interest.A\GAO was asked to examine self-referral for PT services and Medicare spending for these services. This report examines (1) trends in the number of and expenditures for self-referred and non-self-referred Medicare PT services and (2) how provision of these services differs among providers on the basis of whether they self-refer. GAO analyzed Medicare Part B claims data from 2004 through 2010 and examined three measures of PT referral for each referring provider: number of PT services referred, number of beneficiaries referred, and number of PT services provided per beneficiary. GAO compared PT referrals for self-referring and non-self-referring providers after accounting for referring provider specialty, Medicare beneficiary practice size, and geographic (urban or rural) location. GAO also compared selected characteristics of the beneficiaries referred by self-referring and non-self-referring providers.A\The Department of Health and Human Services stated that it had no comments on a draft of this report.A\Chapter 2 - Questions have been raised about selfreferral's role in Medicare Part B expenditures' rapid growth. Self-referral occurs when a provider refers patients to entities in which the provider or the provider's family members have a financial interest. Services that can be self-referred under certain circumstances include IMRT, a common and costly treatment for prostate cancer. GAO was asked to examine Medicare self-referral trends among radiation oncology services. This report examines (1) trends in the number of and expenditures for prostate cancer-related IMRT services provided by self-referring and non-selfreferring provider groups from 2006 through 2010 and (2) how the percentage of prostate cancer patients referred for IMRT may differ on the basis of whether providers self-refer.GAO analyzed Medicare Part B claims and developed a claims-based methodology to identify self-referring groups and providers. GAO also interviewed officials from the Centers for Medicare & Medicaid Services (CMS), which administers Medicare, and other stakeholders.A\Chapter 3 - Questions have been raised about selfreferal's role in Medicare Part B expenditures' rapid growth. Self-referral occurs when providers refer patients to entities in which they or their family members have a financial interest. Services that can be self- referred under certain circumstances include anatomic pathology—the preparation and examination of tissue samples to diagnose disease. GAO was asked to examine the prevalence of anatomic pathology self-referral and its effect on Medicare spending. This report examines (1) trends in the number of and expenditures for self-referred and non-self-referred anatomic pathology services, (2) how provision of these services may differ on the basis of whether providers self-refer, and (3) implications of self-referral for Medicare spending. GAO analyzed Medicare Part B claims data from 2004 through 2010 and interviewed officials from the Centers for Medicare & Medicaid Services (CMS) and other stakeholders. GAO developed a claims-based approach to identify self-referred services because Medicare claims lack such an indicator.A\Chapter 4 - Medicare Part B expenditures—which include payment for advanced imaging services—are expected to continue growing at an unsustainable rate. Questions have been raised about selfreferral's role in this growth. Self-referral occurs when a provider refers patients to entities in which the provider or the provider's family members have a financial interest. GAO was asked to examine the prevalence of advanced imaging self-referral and its effect on Medicare spending. This report examines (1) trends in the number of and expenditures for self-referred and nonself-referred advanced imaging services, (2) how provision of these services differs among providers on the basis of whether they self-refer, and (3) implications of self-referral for Medicare spending. GAO analyzed Medicare Part B claims data from 2004 through 2010 and interviewed officials from the Centers for Medicare & Medicaid Services (CMS) and other stakeholders. Because Medicare claims lack an indicator i entifying self-referred services, GAO developed a claims-based methodology to identify self-referred services and expenditures and to characterize providers as self-referring or not.

Preface vii

Chapter 1 Medicare Physical Therapy: Self-Referring Providers Generally Referred More Beneficiaries but Fewer Services per Beneficiary 1

Chapter 2 Medicare: Higher Use of Costly Prostate Cancer Treatment by Providers Who Self-Refer Warrants Scrutiny 35

Chapter 3 Medicare: Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer 67

Chapter 4 Medicare: Higher Use of Advanced Imaging Services by Providers Who Self-Refer Costing Medicare Millions 107

Index 139

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