Medicare crackdown on MRI brain scans claws back $1.6 million


By Michael Woodhead

5 Aug 2021

Medicare’s claims compliance agency, the Professional Services Review, has reprimanded several radiologists and ordered them to each repay hundreds of thousands of dollars as part of a crackdown on inappropriate claims for MRI brain scans.

In its latest update the PSR reports its investigations into MBS claims by four radiologists which resulted in agreements to repay a total of more than $1.6 million relating to inappropriate rendering of multiple MBS brain and knee items.

The PSR targeted the practitioners after data identified them as the diagnostic radiology specialists with the highest claims for MBS brain imaging such as items 63001 (‘tumour of brain or meninges’), 63049 (‘demyelinating disease of brain’) and 63055 (‘venous sinus thrombosis’).

Among the concerns raised by the PSR were findings that multiple MRI brain and spine MRI items being co-billed where a single service was performed and reported; MRI brain and spine items co-billed with other similar items where not all items were requested or otherwise clinically indicated, and informed consent for interventional procedures performed in association with imaging either not obtained or not adequately documented.

The four practitioners acknowledged having engaged in inappropriate practice in connection with providing the items of concern and they were reprimanded. They agreed to repay sums of $750,000, $538,413, $230,000 and $120,000 respectively, and in some cases were disqualified from providing MBS item services for 12 months.

In its most recent annual report the PSR noted that had broadened its scope of compliance investigations from a historical focus on primary care MBS claims to include specialist MBS items.

“Specialists were reviewed from several physician specialties including cardiology, rheumatology, neurology and neonatology,” the report said.

The PSR is now also focusing on practitioners with high rates of requesting pathology and radiology services such as CT and MRI scans, the report noted.

In 2020 the PSR’s Medicare compliance investigations resulted in repayments of almost $22 million by practitioners found to have overclaimed. The agency received government funding of around $10 million in 2019-20, but the expansion of its compliance activities will see its funding budget grow by 50% to more than $16 million by 2024.

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