Department of Health and Human Services 

OFFICE OF 

 
INSPECTOR GENERAL 

 
 
 
 
 
 
 
 
Q   B
UESTIONABLE  ILLING FOR 

 
M EDICARE INDEPENDENT 

 
D T
IAGNOSTIC  ESTING 

F S  
ACILITY  ERVICES 

 
Daniel R. Levinson 
  
Inspector General
  
 
March 2012
  
OEI-09-09-00380 
  
   
EXECUTIVE SUMMARY:  QUESTIONABLE BILLING FOR MEDICARE 
INDEPENDENT DIAGNOSTIC TESTING FACILITY SERVICES 
OEI-09-09-00380 
 
 
WHY WE DID THIS STUDY 
 
Independent Diagnostic Testing Facilities (IDTF), a type of Medicare provider, offer diagnostic 
services and are independent of physicians offices or hospitals.  IDTF services have historically 
been vulnerable to abuse. In 1997, the Office of Inspector General found that 20 percent of 
IDTFs were not at the locations on file with the Centers for Medicare & Medicaid Services 
(CMS). In 2007, CMS reported that in Los Angeles, it had denied $163 million in IDTF charges 
and terminated Medicare billing privileges for 83 IDTFs.   
 
HOW WE DID THIS STUDY 
 
To describe IDTF billing patterns and identify questionable IDTF claims, we conducted a 
four-part review of such claims among geographic areasspecifically, Core Based Statistical 
Areas (CBSA).   Based on an analysis of all Medicare Part B IDTF claims from 2009, we 
(1) identified the top 20 CBSAs with the highest average Medicare payments per beneficiary 
for IDTF services, terming these high-utilization CBSAs; (2) compared IDTF billing patterns 
in high-utilization CBSAs to such billing patterns in all other CBSAs nationally; (3) identified 
IDTF claims with questionable characteristics; and (4) compared the prevalence of IDTF 
claims with questionable characteristics in high-utilization CBSAs to the prevalence of such 
claims in all other CBSAs.    
 
WHAT WE FOUND 
 
Twenty high-utilization CBSAs accounted for 10.5 percent of Medicare Part B payments for 
IDTF services despite having only 2.2 percent of the total population of beneficiaries.  Almost 
four times more beneficiaries in high-utilization CBSAs received IDTF services than 
beneficiaries in all other CBSAs.  Nine percent of the IDTFs that served beneficiaries in high-
utilization CBSAs provided 90.1 percent of IDTF services.  Additionally, high-utilization CBSAs 
had twice as many claims with at least two questionable characteristics as all other CBSAs.  
 
WHAT WE RECOMMEND 
 
We recommend that CMS:  (1) monitor IDTF claims for questionable characteristics, (2) take 
appropriate action when IDTFs submit a high number of questionable claims, and (3) assess 
whether to impose a temporary moratorium on new IDTF enrollments in CBSAs with high 
concentrations of IDTFs. CMS concurred with all of our recommendations.  
     
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................4 

Findings .......................................................................................................9 

Twenty high-utilization CBSAs accounted for 11 percent of          

Medicare Part B payments for IDTF services despite having                     

only 2 percent of the total population of  Medicare                         

beneficiaries ....................................................................................9 

Nine percent of IDTFs provided 90 percent of IDTF services                 
in high-utilization CBSAs .............................................................10 

High-utilization CBSAs had twice as many IDTF claims with                

at least two questionable characteristics as all other CBSAs ........11 
 
Recommendations......................................................................................13 

Agency Comments and Office of Inspector General Response ....14 

Appendixes ................................................................................................15 

A: Table A-1:  Comparison of High-Utilization Core Based          

Statistical Areas to All Other Core Based Statistical Areas ........15 

B: Table B-1:  Independent Diagnostic Testing Facility Claims
          
With Questionable Characteristics:  Comparison of 
  
High-Utilization Core Based Statistical Areas to All Other  

Core Based Statistical Areas ..........................................................16 

C: Agency Comments  ...................................................................17 

Acknowledgments .....................................................................................20 

   
   
OBJECTIVES 
1. 	  To compare the billing patterns of Independent Diagnostic Testing 
Facilities (IDTF) in high-utilization  areas with the billing patterns of 
IDTFs in other geographic areas.  
2. 	  To identify IDTF claims with questionable characteristics.  
BACKGROUND 
Independent Diagnostic Testing Facilities  
Medicare covers inpatient and outpatient clinical and diagnostic services.  
These services can be provided in a number of settings, including 
physicians offices, hospitals, and IDTFs.  IDTFs, a type of Medicare 
provider, offer diagnostic services and are independent of physicians  
offices or hospitals.1  From 2002 to 2009, substantial growth occurred in 
the number of IDTFs and in Medicare-allowed charges to IDTFs.  The 
number of Medicare-enrolled IDTFs during this time increased from  
2,400 to 6,697, and Medicare-allowed charges for services from IDTFs 
increased from $740 million to $1 billion.2, 3  Previous OIG work has also 
found that high geographic concentrations of providers or services may 
indicate weaknesses in Medicares program safeguards.4    
Services that may be provided by an IDTF include, but are not limited to, 
magnetic resonance imaging, ultrasound, x-rays, and sleep studies.  
Although some IDTF services can be performed remotely, such as 
pacemaker monitoring, most require a patient to be present at a facility.     
Historical Vulnerabilities 
IDTF services have historically been vulnerable to fraud, waste, and 
abuse. IDTFs were originally known as Independent Physiological 
Laboratories (IPL). In 1997, after becoming concerned that IPL services 
were vulnerable to abusein particular, citing a lack of certification 
requirements and confusion about the type of services that IPLs should 
provideCMS issued new standards to address these vulnerabilities.5, 6   
 
1
 42 CFR  410.33(a)(1).
  
2
 Medicare Payment Advisory Commission, Public Meeting:  Characteristics of IDTFs and ambulatory 

surgical centers. Accessed at http://www.medpac.gov/transcripts/0404_allcombined_transcripts.pdf on 
                     
June 7, 2010. 
 
3
 Office of Inspector General (OIG) analysis of 2009 Medicare Part B claims for IDTF services. 
  
4
 OIG,  South Florida Suppliers Compliance With Medicare Standards, OEI-03-07-00150, March 2007, and 

OIG,  Aberrant Billing in South Florida for Beneficiaries With HIV/AIDS,  OEI-09-07-00030, September 2007. 
 
5
 62 Fed. Reg. 59048, 5907172 (Oct.  31, 1997). 
 
6
 62 Fed. Reg. 59048, 5910001 (Oct.  31, 1997) (adding 42 CFR  410.33). 
 
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   1      
   
The new standards modified staffing, certification, and documentation 
requirements for IPLs.  IPLs were also renamed IDTFs to help clarify their 
function. 7  
Also in 1997, OIG conducted site visits to IPLs.  In an August 1998 report 
based on these visits, OIG reported that 20 percent of IPLs were not at the 
locations on file with CMS.8  In the report, OIG also projected 
$11.6 million in improper payments for IPL services and expressed 
concerns that the new standards that CMS had issued would not be 
sufficient to reduce the vulnerabilities that OIG had identified.9  
Despite the new standards, problems with IDTF services persisted.  In a 
2001 review of IDTF services, OIG identified claims that were not 
reasonable, necessary, ordered by a physician, or sufficiently documented 
and projected $71.5 million in improper payments.10  In 2007, CMS 
reported that it had denied $163 million in IDTF charges and terminated 
Medicare billing privileges for 83 IDTFs in Los Angeles.11    
IDTF Enrollments 
An IDTF that wishes to enroll in Medicare must submit an application.  
The application collects a variety of information, including the procedure 
codes for which the applicant intends to bill, the names of supervising 
physicians and technicians, the location where medical records will be 
kept, and the address at which the IDTF will provide services.12    
Before approving an IDTFs enrollment, CMS reviews the application and 
conducts an initial site visit, which may help to ensure that information on 
the application is correct. 
IDTF Billing Requirements  
Services from IDTFs must be ordered in writing by the physician treating 
the beneficiary, and the physician must also use the results of these 
services to manage the beneficiarys medical problem.13  In addition, 
nonphysician practitioners may order tests under appropriate physician 
 
7
 62 Fed. Reg. 59048, 5907172 (Oct.  31, 1997). 
 
8
 OIG,  Independent Physiological Laboratories:  Vulnerabilities Confronting Medicare, OEI-05-97-00240, 
 
August 1998. 
   
9

 Ibid. 

10
 OIG,  Review of Claims Billed by Independent Diagnostic Testing Facilities for Services Provided to 
Medicare Beneficiaries During Calendar Year 2001, A-03-03-00002, June 2006.  
11
 CMS, Testimony  before the House Budget Committee, July 17, 2007.  Accessed at http://www.cms.hhs.gov  
on October 5, 2009. 
 
12
 Form  CMS-855B.  Accessed at http://www.cms.hhs.gov on October 13, 2009. 
 
13
 42 CFR  410.33(d). 
   
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   2      
   
supervision.14   The order must include the diagnosis or the basis for the 
service.   
Postenrollment Site Visits 
According to the Medicare Program Integrity Manual, if an IDTF requests 
an expansion of services and if the new services are sufficiently different 
from those already provided, CMS must conduct a postenrollment site 
visit.15  For example, if an IDTF that provides sleep studies submits a 
request to start providing ultrasound tests, CMS is required to conduct a 
site visit.   
CMS may also conduct postenrollment site visits at its discretion.16  CMS 
cites the use of unannounced site visits as a successful way to determine 
whether IDTFs are operational and at the locations on file with CMS.17   
According to the Medicare Program Integrity Manual, when CMS 
conducts a site visit to verify the operational status of an IDTF, CMS 
should attempt to make its determination using only an external review of 
the IDTF.  CMS requires that reviewers document their visits using written 
observations of the facilities and photographs as appropriate.18    
Temporary Moratoria  
In addition to taking administrative actions against individual IDTFs, 
CMS may also reduce the potential for fraud, waste, or abuse by 
instituting a temporary moratorium on IDTF enrollment.  CMSs authority 
to do this for specific provider types, specific geographic areas, or both 
was established by the ACA and implemented in 2011.19  
Related Work  
OIG conducted two concurrent evaluations of IDTFs to determine whether 
they complied with select Medicare standards.20  The evaluations involved 
conducting unannounced site visits in areas with a high density of IDTFs 
that demonstrated questionable billing patterns.21  
 
14 
 42 CFR  410.32(a)(2).   
15
 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 10,  4.19.6(C).  Accessed at 
http://www.cms.hhs.gov on February  3, 2011.  
16 42 CFR  410.33(g)(14). 
17
 Preamble to final rule implementing sections of the Patient Protection and Affordable Care Act of 2010,   
P.L. 111-148 (ACA).  76 Fed. Reg. 5862, 5869.  (Feb. 2, 2011).  
18
 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 15,  20.1.  Accessed at 

http://www.cms.hhs.gov on February  22, 2011. 
 
19
 ACA,  6401(a)(3) (adding section 1866(j)(6) of the Social Security Act, which was designated as 1866(j)(7) 
 
by the Health Care and Education Reconciliation Act of 2010, P.L. 111-152,  1304).  Implementing 

regulations for  moratoria on newly enrolling Medicare providers and suppliers are at 42 CFR  424.570. 
  
20
 The IDTF Medicare standards are at 42 CFR  410.33. 
 
21
 OIG,  Miami Independent Diagnostic Testing Facilities Compliance With Medicare Standards,                        
OEI-05-09-00560; OIG,  Los Angeles Independent Diagnostic Testing Facilities Compliance With Medicare 
Standards, OEI-05-09-00561.   
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   3      
   
METHODOLOGY 
Scope 
This evaluation is national in scope and is based on an analysis of all 
Medicare Part B IDTF claims from 2009.  We focused the analysis on 
geographic areas with the highest average Medicare payment per 
fee-for-service beneficiary (beneficiary)22 for IDTF services and on claims  
submitted by IDTFs.  We define a geographic area as a Core Based 
Statistical Area (CBSA), which is a geographic area based around an 
urban center of at least 10,000 individuals.23   
Data Sources  
Our data sources consist of the 2009 Part B National Claims History 
(NCH) file from CMS, the 2009 Medicare Part A data file, and the 
2009 Denominator File from the Medicare Enrollment Database.  The 
Part B NCH file contains claims submitted by noninstitutional providers, 
such as physicians, physician assistants, IDTF providers, and nurse 
practitioners. Claims information includes National Provider Identifiers 
(NPI),24  Provider Identification Numbers (provider ID),25 specialty codes, 
diagnosis and procedure codes, dates of service, the beneficiarys Health 
Insurance Claim Number (beneficiary identifier), and payment amounts.  
The CMS Denominator File contains enrollment information about each 
beneficiary enrolled in a given calendar year.26   The Medicare Part A data 
file contains claims that were submitted by institutional providers, such as  
hospitals and skilled nursing facilities. 
Data Collection 
CMS considers an IDTF to be a provider specialty rather than a place of 
service. We analyzed the 2009 Part B NCH file for IDTF claims from  
 
22
 The term fee-for-service beneficiary refers to a  Medicare beneficiary enrolled in a payment system  in 
which providers are paid for each service provided to a beneficiary.  
23
 In 2003, the Office of Management and Budget (OMB) established CBSAs as a new geographic entity.  
OMB designated two categories of CBSAs:  metropolitan statistical areas (based on populations of at least 
50,000 people) and new micropolitan statistical areas (based on a population of 10,00049,999). During our 
review period, there were 955 CBSAs in the United States and Puerto Rico.  OMB,  OMB Bulletin 09-01:   
Update of Statistical Area Definitions and Guidance on Their Uses, November 20, 2008.  Accessed at 
http://www.whitehouse.gov/sites/default/files/omb/assets/omb/bulletins/fy2009/09-01.pdf on                    
September 23, 2010.  
24
 An NPI is the standard 10-digit unique health identifier for health care providers.  CMS, Glossary.  Accessed 
at http://www.cms.gov/apps/glossary/search.asp?Term=npi&Language=English on March 14, 2010.  
25
 A provider ID is a provider identifier that local Medicare contractors assign for each provider practice  
setting.  Thus, a single provider  many have several provider IDs.  National Plan & Provider  Enumeration 
System, NPI Application Help. Accessed at https://nppes.cms.hhs.gov/NPPES/Help.do?topic=OtherID on 
September 27, 2010.   
26
 CMS, Denominator File Identifiable Data Files.  Accessed at 
http://www.cms.gov/IdentifiableDataFiles/06_DenominatorFile.asp on October 1, 2010.   
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   4      
   
practice settings that used only specialty code 47which indicates that a 
claim is for an IDTF serviceto bill Medicare.27  
Using specialty code 47 and provider ID fields in the 2009 Part B NCH 
file, we identified IDTFs that submitted claims in 2009.  We counted each 
provider ID that had claims only with specialty code 47 as an IDTF.  The 
final file included 5,974,969 claims representing $798 million in Medicare 
payments for IDTF services from 6,697 IDTFs.  
Analysis  
To describe IDTF billing patterns and identify questionable IDTF claims, 
we conducted a four-part review of such claims.  First, we identified 
CBSAs with the highest average Medicare payments per beneficiary for 
IDTF services. Second, we compared IDTF billing patterns in those 
CBSAs to such billing patterns in all other CBSAs.  Third, we identified 
IDTF claims with questionable characteristics.  (We describe these 
characteristics in detail on pages 7 and 8 of this report.)  Finally, we 
compared the prevalence of such IDTF claims in the two groups of 
CBSAs (i.e., CBSAs with the highest average Medicare payments per 
beneficiary for IDTF services and all other CBSAs).  
Identification of high-utilization CBSAs. Using the 2009 Part B NCH file 
and the 2009 Denominator File, we identified CBSAs with the highest 
average Medicare Part B payments per beneficiary for IDTF services in 
2009. We determined the CBSA to which each beneficiary belonged by  
matching the ZIP Code field from the Part B NCH file and the 
Denominator File with the ZIP Codes corresponding to each CBSA.  We  
used the 2009 Denominator File to count the number of beneficiaries in 
each CBSA. We then merged the 2009 Part B NCH file and the 
2009 Medicare denominator file by CBSA.  To calculate the average 
Medicare payments per beneficiary for IDTF services within each CBSA, 
we divided the total Medicare payments for IDTF services in 2009 by the 
number of all beneficiaries in each CBSA. 
We analyzed this file to identify the CBSAs (among the total of 
955 CBSAs) with the highest average IDTF payment per beneficiary.   
From this group, we selected the top 20 CBSAs, which we defined as 
high-utilization CBSAs. See Figure 1 for a map showing their locations. 
 
27
 We analyzed claims from practice  settings that billed using specialty code 47 only.  We did not include 
practice settings that bill using multiple specialty codes.  We focused our study in this manner to analyze the 
same type of claims as OIGs two concurrent IDTF  evaluations that conducted site visits to IDTFs.  To best 
target their site visits, the evaluation teams that conducted the concurrent evaluations had to identify locations 
most likely to be IDTFs.  They did this by selecting practice settings that billed using only IDTF specialty  
code 47.     
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   5      
   
 
   
 Figure 1:   High-Utilization CBSAs, 2009   
 
 
 
 
 
    
 
 
 
   
 
 
 
   
   
 
 
 
 
             
 
 
 
       
 
 
 
 
           Source:  OIG  analysis of 2009 Medicare Part  B IDTF claims.  
 
Comparison of high-utilization CBSAs to all other CBSAs.   We compared 
IDTF billing patterns in these 20 high-utilization CBSAs to IDTF billing 
patterns in all other CBSAs.  We  did this by identifying the CBSAs 
corresponding to the claims in the 2009 Part B NCH file and the 
2009 Medicare Denominator File, based on the beneficiarys CBSA.  
First, we summarized the 2009 Part B NCH file by CBSA to generate 
totals of IDTF services, payments, and beneficiaries who received IDTF 
services in high-utilization CBSAs and in all other CBSAs.  We used the 
2009 Medicare Denominator File to obtain a count of beneficiaries in 
high-utilization CBSAs and in all other CBSAs.  We merged these files to  
calculate utilization measures in high-utilization CBSAs and all other 
CBSAs and compared these utilization measures.  Utilization measures 
that we calculated include: 
   the percentage of beneficiaries who received at least one IDTF service; 
   the average number of IDTF services received per beneficiary; 
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   6     
   
 	  the average Medicare payment per beneficiary who received IDTF 
services; 
 	  the number of IDTFs per 10,000 beneficiaries;28 and, 
 	  the number of IDTF services those IDTFs provided. 
Identification of questionable characteristics.   We developed a list of three 
characteristics that may identify questionable IDTF claims.  We based this 
list on IDTF requirements and previous OIG work that analyzed billing 
patterns.29   The characteristics include:  
1.	   Claims involving a beneficiary linked to four or more IDTFs. A  
beneficiary linked to four or more IDTFs is one who had claims  
submitted from four or more IDTFs in a 1-year period.  The presence 
of claims for beneficiaries who are linked to four or more IDTFs may 
indicate that providers are inappropriately sharing beneficiary 
identifiers.30  
2. 	  Claims for which beneficiaries did not see their referring physicians 
within 90 days before or after receiving the IDTF service. We  
identified the referring physician listed on each IDTF claim and 
determined whether the physician had a claim for treating the 
beneficiary within 90 days before or after the beneficiary received the 
IDTF service. We looked at noninstitutional and institutional claims.31    
The absence of a claim within 90 days before or after the beneficiary 
received the IDTF service may indicate that the referring physician is 
not the treating physician.32  
3.	   IDTF claims on which the diagnosis category33 is not the same as the 
diagnosis category on any other corresponding provider claim for that 
beneficiary. We looked at noninstitutional and institutional claims  
90 days before and after the beneficiary received the IDTF service.  
 
28
 For ease of reporting, our unit of analysis to measure the concentration of IDTFs in CBSAs is based on the 
number of IDTFs per 10,000 Medicare beneficiaries. 
29
 OIG,  Medicare Part B Billing for Ultrasound, OEI-01-08-00100, June 2009.  
30
 This characteristic was based on OIG,  Medicare Part B Billing for Ultrasound, OEI-01-08-00100,  
June 2009.   
31
 Institutional claims under the Medicare Part A and B data files that we reviewed include claims from  
hospitals, nursing facilities, renal dialysis facilities, hospices, federally qualified health centers, and rural health 
clinics. 
32
 This characteristic was based on OIG,  Medicare Part B Billing for Ultrasound, OEI-01-08-00100,  
June 2009.   
33
 We determined diagnosis categories based on the Clinical Classification Software system for International 
Classification of Diseases, 9th edition Clinical Modification developed by the Agency for Healthcare Research 
and Quality.  Accessed at http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp on September 29, 2010.   
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   7      
   
The difference in diagnosis categories may indicate that unnecessary 
services were provided.34   
Comparison of IDTF claims with questionable characteristics in 
high-utilization CBSAs and such claims in all other CBSAs. We  
determined whether any of the three questionable characteristics were 
present on IDTF claims.  We compared the presence of each characteristic 
on IDTF claims from high-utilization CBSAs and on IDTF claims from all 
other CBSAs. Next, we determined how often at least two of the three 
characteristics were present on IDTF claims.  We compared how often at 
least two of the three questionable characteristics were present on IDTF 
claims from high-utilization CBSAs and on IDTF claims in all other 
CBSAs. 
Limitations 
We did not conduct a medical review to determine whether services were 
provided, whether services were medically necessary, or whether claims  
were coded correctly. 
The three characteristics that we used to identify questionable claims are 
not intended to be a comprehensive set of characteristics for identifying 
questionable billing. Further, while the presence of such characteristics 
raises questions about the appropriateness of a given IDTF claim, it does 
not necessarily mean that such claims are inappropriate or fraudulent.  
Our 2009 Part B NCH file (5,974,969 IDTF claims) for IDTF services 
included 43,039 IDTF claims in which the IDTF listed its own NPI as that 
of the referring physician.35  CMS instituted a temporary provision 
allowing billing providers to use their own NPIs in the required field for 
the referring physicians NPI if the billing provider cannot obtain the 
referring physicians NPI.36   To be conservative, we counted these 
43,039 claims as though the beneficiaries involved had all seen a referring 
physician within 90 days before or after receiving IDTF services.  
Therefore, our results may underestimate the number of beneficiaries who 
did not see a referring physician within that timeframe.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection  and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
 
34
 We developed this characteristic based on the requirement that IDTF services be ordered in writing by the 

physician who is treating the beneficiary and that the order include the diagnosis or the basis for the service. 
    
42 CFR  410.33(d). 
 
35
 There were 613 IDTFs that entered their own NPIs in the field for the referring physicians  NPI at least once. 
 
36
 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 14,  14.5.  Accessed at 

http://www.cms.hhs.gov/manuals/downloads/pim83c14.pdf on March 23, 2011. 
 
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FINDINGS 
Twenty high-utilization CBSAs accounted for 
11 percent of Medicare Part B payments for IDTF 
services despite having only 2 percent of the total 
population of Medicare beneficiaries   
High-utilization CBSAs accounted for 10.5 percent ($75.8 million of 
$797.9 million) of the Medicare Part B payments for IDTF services in 
2009.  However, only 2.2 percent (828,834 of 37.2 million) of  
beneficiaries reside in the high-utilization CBSAs.   
Almost four times more beneficiaries in high-utilization  CBSAs 
received IDTF services than beneficiaries in all other CBSAs 
Beneficiaries in high-utilization CBSAs received more IDTF services than 
beneficiaries in all other CBSAs. In 2009, 22.9 percent of beneficiaries in 
high-utilization CBSAs received IDTF services, compared to 6.2 percent 
of beneficiaries in all other CBSAs. The percentage of beneficiaries who 
received IDTF services in high-utilization CBSAs ranged from  
15.2 percent in Troy, Alabama, to 38.8 percent in Jennings, Louisiana.  
The CBSAs with the next-highest percentages of beneficiaries who 
received IDTF services were Poplar Bluff, Missouri (35.0 percent), and 
Las Cruces, New Mexico (30.4 percent).  See Appendix A, Table A-1, for 
details on use of IDTF services in high-utilization CBSAs and all other 
CBSAs. 
On average, beneficiaries in high-utilization CBSAs received 
more IDTF services than beneficiaries in all other CBSAs 
On average, beneficiaries who received IDTF services in high-utilization 
CBSAs received slightly more such services than beneficiaries in all other 
CBSAs. Beneficiaries who received IDTF services in high-utilization 
CBSAs received an average of 3.5 such services, compared to 2.4 such 
services in all other CBSAs.  The number of IDTF services per beneficiary 
who received such a service in high-utilization CBSAs ranged from 2.5 in 
Yuma, Arizona, to 4.5 in Kerrville, Texas.  The CBSAs with the 
next-highest number of IDTF services per beneficiary were Granbury,  
Texas (4.3), and Duncan, Oklahoma (4.1).    
The average Medicare payment per beneficiary who received 
an IDTF service in high-utilization CBSAs was almost 
25 percent higher than in all other CBSAs 
The average Medicare payment per beneficiary receiving IDTF services in 
high-utilization CBSAs was $399.90, compared to $321.33 in all other 
CBSAs. The average Medicare payment per beneficiary receiving such 
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services in high-utilization CBSAs ranged from $229.56 in Santa Fe, 
New Mexico, to $484.90 in Troy, Alabama.   The CBSAs with the 
next-highest average payment per beneficiary were Miami 
Fort LauderdalePompano Beach, Florida ($457.75), and Kerrville, Texas 
($414.87).   
Nine percent of IDTFs provided 90 percent of IDTF 
services in high-utilization CBSAs 
A small number of IDTFs provided most of the IDTF services in 
high-utilization CBSAs. Although 1,676 IDTFs provided at least 1 such 
service to beneficiaries in high-utilization CBSAs, 90.1 percent 
(601,933 of 668,252) of the services were provided by only 9.0 percent 
(151) of those IDTFs. In all other CBSAs, 6,620 IDTFs provided at least 
1 such service to beneficiaries; however, 90.0 percent (4,769,358 of 
5,306,717) of the services were provided by 24.1 percent (1,593) of those 
IDTFs.37  Billing patterns in each high-utilization CBSA  were consistent 
with the collective IDTF billing patterns among high-utilization CBSAs.  
For example, in Yakima, Washington, although 66 IDTFs provided at least 
1 IDTF service to beneficiaries in that CBSA, 2 IDTFs provided 
89.5 percent of such services to beneficiaries.  Similarly, in Danville, 
Virginia, 45 IDTFs provided at least 1 IDTF service to beneficiaries, and a 
single IDTF provided 93.4 percent of such services to beneficiaries.   
Even though a small number of IDTFs provided most of the IDTF services 
to beneficiaries in high-utilization CBSAs, there was a higher 
concentration of IDTFs in those CBSAs than in all others.  There was an 
average of 88.3 IDTFs per 10,000 beneficiaries in high-utilization CBSAs, 
compared to an average of 29.5 per 10,000 beneficiaries in all others. 
Seventy-one percent of IDTFs providing services to 
beneficiaries in high-utilization CBSAs were in the MiamiFort 
LauderdalePompano Beach, Florida, CBSA 
Of the 9.0 percent (151 of 1,676) of IDTFs that provided 90.1 percent of 
IDTF services to beneficiaries in high-utilization CBSAs, 70.8 percent  
(107 of 151) were in the MiamiFort LauderdalePompano Beach, 
Florida, CBSA (see Table 1).  These 107 IDTFs accounted for 5.2 percent 
($41.1 million) of the Medicare payments for all IDTF services in 2009.  
However, only 1.4 percent (518,837 of 37.2 million) of beneficiaries 
resided in that CBSA. In addition, the average Medicare payment per 
beneficiary who received an IDTF service from these 107 IDTFs was 
 
37 The percentage of IDTFs that provided 90 percent of IDTF services is based on IDTFs that submitted claims  
to Medicare for reimbursement, not on the percentage of Medicare-enrolled IDTFs.   
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$438.98, compared to $294.14 among the remaining 44 IDTFs in this 
group. These 107 IDTFs provided an average of 4.1 IDTF services to  
beneficiaries in high-utilization CBSAs, compared to 2.9 IDTF services 
among the remaining 44 IDTFs in this group. 
Table 1. Billing Patterns From IDTFs That Provided 90 Percent of IDTF Services to 
Medicare Beneficiaries in High-Utilization CBSAs 
Average 
Average  
Number of  
Medicare 
Number of   IDTF 
Number of   Number of    Payment 
IDTFs That  Services  
IDTF  Beneficiaries  per 
Provided  per 
CBSA   Services   Who  Total   Beneficiary  
IDTF  Beneficiary  
Where the  Provided to   Received  Medicare  Who 
Services to    Who 
IDTFs Were  Beneficiaries  Services in  Payments for  Received 
Beneficiaries  Received 
Located   in High- High- IDTF Services   IDTF 
in High- Such 
Utilization  Utilization  Services in 
Utilization  Services   
CBSAs    CBSAs   High-
CBSAs    in High-
Utilization 
Utilization 
CBSAs   
CBSAs   
MiamiFort 
Lauderdale      
107  93,708  4.1  $438.98  
Pompano  379,748  $41,135,779.96  
Beach, FL  
 
Other High-
44  222,185   75,766   $22,285,647.37   2.9  $294.14  
Utilization 
CBSAs 
 
151  601,933   168,059   $63,421,427.33   3.6  $377.38  
Total  
Source:   OIG analysis of 2009 Medicare Part B IDTF claims. 
 
High-utilization CBSAs had twice as many IDTF claims 
with at least two questionable characteristics as all 
other CBSAs  
In 2009, 17.5 percent of IDTF claims  in high-utilization CBSAs had at 
least two questionable characteristics, compared to 8.0 percent of IDTF 
claims in all other CBSAs.  These IDTF claims accounted for 
$10.0 million (12.5 percent) of the Medicare payments for IDTF services 
in high-utilization CBSAs. See Appendix B, Table B-1, for a list of 
high-utilization CBSAs with the corresponding percentages of claims with 
at least two questionable characteristics.   
Five times more IDTF claims in high-utilization CBSAs than in 
all other CBSAs involve a beneficiary linked to four or more 
IDTFs   
In high-utilization CBSAs, 15.4 percent (103,220 of 668,252) of IDTF 
claims involve a beneficiary linked to four or more IDTFs, compared to 
2.7 percent of such claims in all other CBSAs.  The presence of claims for 
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   11      
   
beneficiaries linked to four or more IDTFs may indicate that providers are 
inappropriately sharing beneficiary identifiers.  The percentage of IDTF 
claims for which the beneficiary was linked to four or more IDTFs ranged 
from 0.2 percent in Duncan, Oklahoma, to 21.7 percent in MiamiFort 
LauderdalePompano Beach, Florida.  The high-utilization CBSAs with 
the next-highest percentages were Lafayette, Louisiana (9.1 percent), and 
Fayetteville, North Carolina (6.1 percent).   
Seventeen percent of IDTF claims in high-utilization CBSAs 
had no corresponding claim by the referring physician  
In high-utilization CBSAs, 17.3 percent (115,669 of 668,252) of IDTF 
claims had no corresponding claim by the referring physician within 
90 days before or after the beneficiary received the IDTF service, 
compared to 14.2 percent of IDTF claims in all other CBSAs.  The 
absence of a claim 90 days before or after receiving the IDTF service may 
indicate that the referring physician is not the treating physician.  The 
percentage of IDTF claims that had no corresponding claim by the 
referring physician ranged from 5.4 percent in Rio Grande CityRoma, 
Texas, to 21.8 percent in Santa Fe, New Mexico.  The high-utilization 
CBSAs with the next-highest percentages were Fayetteville, 
North Carolina (21.7 percent), and MiamiFort Lauderdale 
Pompano Beach, Florida (19.5 percent).  
More than 46 percent of claims in high-utilization CBSAs did 
not have the same diagnosis categories as any other 
corresponding provider claims   
In high-utilization CBSAs, 46.7 percent (311,910 of 668,252) of IDTF 
claims did not have the same diagnosis categories as any other 
corresponding provider claims 90 days before or after the beneficiary 
received an IDTF service, compared to 35.4 percent of IDTF claims in all 
other CBSAs. If the diagnosis category on the IDTF claim is not the same  
as that on any other corresponding provider claim within 90 days before or 
after the beneficiary received the IDTF service, it may indicate that the 
IDTF provided unnecessary services.   The percentage of IDTF claims on 
which the diagnosis categories did not match any other provider claims  
ranged from 2.7 percent in Grand Island, Nebraska, to 61.5 percent in 
Santa Fe, New Mexico. The high-utilization CBSAs with the next-highest 
percentages were East Stroudsburg, Pennsylvania (55.1 percent), and 
MiamiFort LauderdalePompano Beach, Florida (52.2 percent).   
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   12      
   
RECOMMENDATIONS 
This report found that high-utilization CBSAs accounted for 10.5 percent 
of Medicare Part B payments for IDTF services despite having only 
2.2 percent of the total population of beneficiaries.  Almost four times 
more beneficiaries in high-utilization CBSAs received IDTF services than 
beneficiaries in all other CBSAs. Nine percent of the IDTFs that served 
beneficiaries in high-utilization CBSAs provided 90.1 percent of IDTF 
services.  Additionally, high-utilization CBSAs had twice as many claims 
with at least two questionable characteristics as all other CBSAs.  
Another OIG review of IDTFsLos Angeles Independent Diagnostic 
Testing Facilities Compliance With Medicare Standards  
(OEI-05-09-00561)recommended that CMS impose a moratorium on 
new IDTF enrollments in the Los Angeles area while CMS develops 
additional safeguards for IDTFs in the area.  Because services provided by 
IDTFs are also available at physicians  offices and hospitals, an enrollment 
moratorium on IDTFs is unlikely to have a negative impact on 
beneficiaries access to these services.   
We recommend that CMS: 
Monitor IDTF claims for questionable characteristics  
CMS should monitor IDTF claims for questionable characteristics to 
identify vulnerabilities. Claims exhibiting readily identifiable 
questionable characteristics may include those on which the beneficiaries 
were linked to four or more IDTFs; claims that lacked corresponding 
claims by the referring physicians; and claims for which the diagnosis 
categories were not the same as those on any other provider claims for 
those beneficiaries. 
Take appropriate action when IDTFs submit a high number of 
questionable claims  
When IDTFs are found to have a high rate of questionable billing 
characteristics, CMS should review those claims before payment to ensure 
that they are appropriate. If CMS determines that inappropriate claims  
have been submitted, it should take steps to suspend payments for these 
providers and/or recover inappropriate payments made to them.   
Assess whether to impose a temporary moratorium on new  
IDTF enrollments in CBSAs with  high concentrations of IDTFs 
Given that a small number of IDTFs provide most IDTF services in 
high-utilization CBSAs, CMS should assess whether to impose a 
temporary moratorium on new IDTF enrollments in those CBSAs.  Such a 
moratorium would prevent new enrollments while CMS develops program 
safeguards, such as more frequent in-depth reviews of lDTFs.  In the 
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   13      
   
report entitled Los Angeles Independent Diagnostic Testing Facilities  
Compliance With Medicare Standards (OEI-05-09-00561), OIG 
recommended that CMS impose a moratorium on new IDTF enrollments 
in the Los Angeles area.  
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
In its written comments on our draft report, CMS concurred with all of our 
recommendations.  CMS stated that it is using predictive modeling 
technology to detect and generate alerts for suspicious billing by IDTFs.  
CMS indicated that it is using authorities granted in the ACA to address 
potential vulnerabilities in the enrollment and claims payments processes 
for IDTFs. 
In our draft report, we recommended that CMS monitor IDTF claims for 
questionable characteristics.  In response, CMS stated that it is streaming 
every Medicare fee-for-service claim before payment through its 
predictive modeling technology, known as FPS.  The FPS uses a series of 
algorithms to identify potentially fraudulent claims and prioritize the most 
egregious situations. CMS is intent on building reliable models in the FPS 
that can detect and generate alerts for suspicious billing by all major 
provider types, including IDTFs. Furthermore, IDTFs have been and will 
remain a key focus for CMSs program integrity operations.  OIG supports 
CMSs continued development of FPS and its predictive modeling efforts 
to identify fraudulent claims and prevent payments.  
We recommended that CMS take appropriate action when IDTFs submit a 
high number of questionable claims.  In response, CMS stated that it is 
taking a variety of administrative actions against many provider types 
around the Nation, including IDTFs. Administrative actions may include, 
but are not limited to, verification of operational status, prepayment 
review, auto-deny edits, payment suspensions, and revocations.  OIG 
supports CMSs administrative action efforts and agrees that they may 
help address IDTFs that submit a high number of questionable claims.      
In our draft report, we recommended that CMS assess whether to impose a 
temporary moratorium on new IDTF enrollments in CBSAs with high 
concentrations of IDTFs. In response, CMS stated that in developing its 
approach for implementing the new temporary moratorium authority, it 
will assess whether moratoria are appropriate for a variety of provider 
types, including IDTFs. OIG supports CMSs use of a variety of data and 
information, including factors such as high concentration of IDTFs and 
high IDTF utilization, to determine whether a moratorium would be 
appropriate. For the full text of CMSs comments, see Appendix C. 
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   14      
   
 
APPENDIX A 
Table A-1. Comparison of High-Utilization Core Based Statistical Areas to All Other Core  
Based Statistical Areas  
  Percentage of 
Average Payment 
Medicare Beneficiaries  
Average Number of  per Medicare  
Core Based Statistical Areas (CBSA)   Who Received  
IDTF Services per   Beneficiary Who 
(Alphabetical Order)   Independent 
Medicare Beneficiary   Received  IDTF 
Diagnostic Testing 
Services 
Facility (IDTF) Services   
1  Alamogordo, New Mexico   22.0%  2.7  $358.67 
2  Danville, Virginia    30.3%  2.6  $266.83 
3  Duncan, Oklahoma  28.3%  4.1  $273.91 
4  East Stroudsburg, Pennsylvania   26.4%  2.7  $337.11 
5  Fayetteville, North Carolina  26.5%  2.6  $258.87 
6  Granbury, Texas   24.8%  4.3  $327.96 
7  Grand Island, Nebraska  23.8%  2.9  $354.14 
8  Jennings, Louisiana  38.8%  2.8  $284.63 
9  Kerrville, Texas   16.4%  4.5  $414.87 
10  Lafayette, Louisiana  22.0%  3.0  $354.75 
11  Las Cruces, New Mexico  30.4%  3.2  $325.72 
MiamiFort LauderdalePompano  
12  21.5%  3.9  $457.75 
Beach, Florida  
13  Natchez, MississippiLouisiana  28.9%  3.0  $344.38 
14  OpelousasEunice, Louisiana  19.0%  3.0  $354.71 
15  Poplar Bluff, Missouri  35.0%  3.4  $338.13 
16  Rio Grande CityRoma, Texas   20.4%  2.7  $339.44 
17  Santa Fe, New  Mexico  29.4%  3.1  $229.56 
18  Troy, Alabama   15.2%  3.1  $484.90 
19  Yakima, Washington  21.8%  2.6  $308.70 
20  Yuma, Arizona   22.4%  2.5  $387.65 
All High-Utilization CBSAs Combined   22.9%  3.5  $399.90 
 
All Other  CBSAs   6.2%  2.4  $321.33 
 
 
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   15      
   
APPENDIX B 
Table B-1. Independent Diagnostic Testing Facility Claims With Questionable 
Characteristics:  Comparison of High-Utilization Core Based Statistical Areas to All Other 
Core Based Statistical Areas  
Percentage 
Total  Percentage  
of IDTF 
Number of  Percentage of  of IDTF  Percentage of 
Claims on 
Independent  IDTF Claims  Claims That  IDTF Claims 
Which the 
Core Based Statistical Areas  Diagnostic  With Two or   Lacked a  With  
  Medicare 
(CBSA) (Alphabetical Order)   Testing  More  Claim by   Unmatched 
Beneficiary  
Facility   Questionable  the  Diagnosis 
Is Linked to  
(IDTF)  Characteristics    Referring  Categories   
Four or 
Claims   Physician  
More IDTFs   
   
1  Alamogordo, New Mexico   2.6%  2.0%   14.1%   10.0%  
5,336 
   
2  Danville, Virginia    9.5%  0.3%   13.4%   49.7%  
15,717 
   
3  Duncan, Oklahoma  3.6%  0.2%   6.3%   43.5%  
10,012 
   
4  East Stroudsburg, Pennsylvania   12.0%  1.8%   15.4%   55.1%  
16,382 
   
5  Fayetteville, North Carolina  10.1%  6.1%   21.7%   36.1%  
25,874 
   
6  Granbury, Texas   5.9%  2.6%   9.6%   38.6%  
12,248 
   
7  Grand Island, Nebraska  0.8%  2.6%   6.4%   2.7%  
7,169 
   
8  Jennings, Louisiana  1.8%  3.1%   8.4%   5.8%  
5,582 
   
9  Kerrville, Texas   1.4%  1.8%   9.7%   10.3%  
9,715 
   
10  Lafayette, Louisiana  11.0%  9.1%   12.3%   46.2%  
21,807 
   
11  Las Cruces, New Mexico  7.5%  5.7%   12.8%   39.0%  
23,242 
MiamiFort Lauderdale     
12  22.7%  21.7%   19.5%   52.2%  
Pompano Beach, Florida   435,781 
   
13  Natchez, MississippiLouisiana  5.4%  5.5%   14.8%   21.1%  
8,886 
   
14  OpelousasEunice, Louisiana  9.0%  3.7%   11.7%   46.3%  
8,811 
   
15  Poplar Bluff, Missouri  5.3%  3.7%   11.5%   26.1%  
10,164 
   
16  Rio Grande CityRoma, Texas   3.0%  3.3%   5.4%   23.0%  
4,072 
   
17  Santa Fe, New  Mexico  16.8%  2.5%   21.8%   61.5%  
16,704 
   
18  Troy, Alabama   6.8%  1.6%   8.7%   45.3%  
2,247 
   
19  Yakima, Washington  2.7%  1.7%   8.3%   11.4%  
16,160 
   
20  Yuma, Arizona   7.5%  3.5%   11.1%   43.0%  
12,343 
All High-Utilization CBSAs  
  668,252  17.5%   15.4%   17.3%   46.7%  
Combined  
  All Other  CBSAs   5,306,717  8.0%   2.7%   14.2%   35.4%  
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   16    APPENDIXC 
Agency Comments 
/fP.o;lC:~.~ 
~
(  DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers lor Medicare & Medicaid Services 
Office 01 Strat. Opef8tions 
<~~  and RflgtJls/O<y Aff....
200 Independence Avenue SW 
Washington, DC 20201 
DATE:  DEC  2 3 2011 
TO: 	 Daniel R. Levinson 

ll\~peotor General 

FROM: 	 Mwil,yn TjlVenner 

Acting Aibninis1rator 

SUBJECT: 	 Office of Inspector General (OIG) Draft Report: "Questionable Billing for 
Medicare Independent Diagnostic Testing Facility Services" (OEI-09-09-00380) 
'The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office oflnspector General (010) draft report entitled, "Questionable Billing 
for Medicare Independent Diagnostic Testing Facility Services." The purpose ofthis report was 
to compare the billing patterns oflndependent Diagnostic Testing Facilities (IDTFs) in high
utilization areas with billing patterns oflDTFs in other geographic areas and to identify IDTF 
claims with questionable characteristics. 
IDTFs offer diagnostic services and are independent of a physician's office or hospital. 

According to OIG's report, the number ofMedicare- enrolled IDTFs from 2002 to 2009 

substantially grew, as did the Medicare-allowed charges for IDTFs. 

IDTF services have historically been vulnerable to abuse. CMS is currently streaming every 
Medicare fee-for-service claim in real-time through its predictive modeling technology, known 
as the Fraud Prevention System (FPS). 'The FPS uses a series of algorithms to identify 
potentially fraudulent claims and prioritize the most egregious situations. As each claim streams 
through the predictive modeling system, the system builds profiles ofproviders, networks, and 
billing patterns. Using these profiles, CMS estimates a claim's likelihood offraud and prioritizes 
providers with billing behavior that seem to pose an elevated risk to Medicare for a closer 
review. CMS will explore opportunities to build reliable models in the FPS that Can detect and 
generate alerts for suspicious billing behavior by IDTFs. 
In addition, CMS is taking additional steps to address potential vulnerabilities in the enrollment 
and claims payment process for this supplier group using the authorities granted under the 
Affordable Care Act. Under the new screening provisions ofCMS 6028-FC1 alllDTFs are 
I eMS 6028.FC entitled, uMedicare, Medicaid and Children's Health Insurance Programs; Additional Screening 
Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for 
Providers and Suppliers" was published in the Federal Register on February 2, 20 II . 
OEI-09-09-00380  Questionable Billing for Medicare IDTF Services  17   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
OEI-09-09-00380  Questionable Billing for Medicare IDTF Services  18     
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
OEI-09-09-00380  Questionable Billing for Medicare IDTF Services  19     
   
Acknowledgments 
This report was prepared under the direction of Timothy S. Brady,  
Regional Inspector General for Evaluation and Inspections in the San 
Francisco regional office, and Michael Henry, Deputy Regional Inspector 
General. 
Veronica Gonzalez served as the team leader for this study, and  
Loul Alvarez served as lead analyst.  Other principal Office of Evaluation 
and Inspections staff from the San Francisco regional office who 
contributed to the report include Christina Lester; central office staff who 
contributed include Robert Gibbons, Scott Horning, Scott Hutchison, and 
Kevin Manley. 
 
OEI-09-09-00380   Questionable Billing for Medicare IDTF Services   20      
Office of Inspector General 

http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is  
to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the 
health and welfare of beneficiaries served by those programs.  This statutory mission is carried out through 
a nationwide network of audits, investigations, and inspections conducted by the following operating 
components: 
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The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with 
its own audit resources or by overseeing audit work done by others.  Audits examine the performance of  
HHS programs and/or its grantees and contractors in  carrying out their respective responsibilities and are  
intended to provide independent assessments of HHS programs and operations.  These assessments help 
reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections  
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, 
and the public with timely, useful, and reliable information on significant issues.  These evaluations focus 
on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of  
departmental programs.  To promote impact, OEI reports also present practical recommendations for 
improving program operations.  
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The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and 
misconduct related to HHS programs, operations, and beneficiaries.  With investigators working in all 
50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the  
Department of Justice and other Federal, State, and local law enforcement authorities.  The investigative 
efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support for OIGs internal  
operations.  OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS 
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connection with these cases, OCIG also negotiates and monitors corporate integrity agreements.  OCIG 
renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
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authorities.