Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
  Q  
UESTIONABLE
 
B P  
IL  LING  ATTERNS OF 
 
P X-R S  
ORTABLE  AY  UPPLIERS
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
December 2011 
OEI-12-10-00190   E X E C U T I V E   S U M M A R Y  
OBJECTIVES
 
1.  To identify portable x-ray suppliers with questionable billing 
patterns that may be associated with inappropriate Medicare 
payments. 
2.  To identify claims for portable x-ray services that may warrant 
further review. 
BACKGROUND 
Medicare paid portable x-ray suppliers approximately $225 million 
under the Part B benefit in 2009 for x-rays of the extremities, pelvis, 
spine, skull, chest, and abdomen.  Portable x-ray suppliers provide 
diagnostic imaging services at patients locationsmost often 
residences, including private homes and group living facilities, such as 
nursing homesrather than in a traditional clinical setting, such as a 
doctors office or hospital.  Medicare pays portable suppliers separately 
for up to four components of the service:  transporting the equipment to 
the beneficiarys location, setting it up for use, administering the test, 
and interpreting the results.  Eighty percent of the amount Medicare 
paid to portable suppliers in 2009 reimbursed them for transporting and 
setting up the x-ray equipment. 
Federal regulations stipulate that portable x-rays must be ordered by a 
licensed medical doctor or doctor of osteopathy who is treating the 
beneficiary for a specific medical problem and who uses the results of 
the x-ray in managing it.  The order must also state the need for 
portable services. 
Medicare pays for the full transportation component once for each trip 
to a particular location.  For example, if a supplier furnishes chest        
x-rays to three patients at one nursing home during a single trip, 
Medicare pays one-third the full transportation component rate for each 
patient.  While it pays the full rate only once per trip, Medicare pays 
that full rate again for each return trip to a facility on a particular day. 
We used Medicare claims data to assess portable x-ray suppliers on 
eight characteristics we developed that describe questionable billing 
patterns:  (1) portable services ordered by nonphysicians, (2) no recent 
contact between beneficiary and ordering provider, (3) same-day 
services in multiple settings, (4) billing for return trips, (5) portable       
x-rays per beneficiary, (6) beneficiary contact with multiple portable 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  i  E X E C U T I V E   S U M M A R Y  
suppliers, (7) beneficiary use of stationary x-ray services, and               
(8) beneficiary DME utilization.  We also merged these characteristics 
into a combined score for each supplier describing its overall billing 
pattern.  We then identified thresholds for each characteristic and the 
combined score, which, if exceeded by a supplier, signified questionable 
billing.  In addition, we analyzed claims data to determine the total 
amount Medicare paid for portable services ordered by nonphysicians 
and for apparent return trips to facilities. 
FINDINGS 
Twenty portable x-ray suppliers exhibited questionable billing 
patterns.  We identified 20 suppliers that exceeded thresholds on at 
least 2 of the characteristics of questionable billing we developed and 
exceeded the threshold for the combined score.  Thirteen of these 
suppliers were located in the Miami, Florida, area. 
Medicare paid portable x-ray suppliers approximately $12.8 million 
for return trips to nursing facilities.  As a typical example, one supplier 
submitted a claim for the full transportation component for each of two 
beneficiaries on a particular day (rather than one-half of the full 
transportation component for two beneficiaries on a particular day) and 
each claim was paid at the full rate.  However, data show that these two 
beneficiaries were located in the same nursing home on that date.  
Claims data do not provide sufficient information to determine whether 
the supplier billed correctly for two separate trips to the facility or 
whether the supplier administered tests to the two beneficiaries during 
a single trip and incorrectly claimed full reimbursement of the 
transportation component for each beneficiary. 
Medicare paid at least $6.6 million for portable x-ray services that 
were ordered by nonphysicians and therefore not covered.  Nurse 
practitioners ordered $4.3 million of these services, while physician 
assistants and podiatrists ordered $1 million and $900,000, respectively.  
Registered nurses, chiropractors, and other medical professionals 
accounted for the remainder.  Medicare paid an additional $5.9 million 
for services for which we could not determine the credentials of the 
ordering providers. 
 
 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  ii  E X E C U T I V E   S U M M A R Y  
RECOMMENDATIONS 
Portable x-rays constitute a small portion of overall Medicare payments 
for diagnostic imaging services, but the questionable claims patterns we 
found raise concerns about the integrity of payments to certain 
suppliers.  Furthermore, payments for portable services ordered by 
nonphysicians clearly violate Federal regulations and should be 
recovered.  Lastly, payments for return trips to facilities, while not 
necessarily inappropriate, may represent an additional opportunity for 
program savings.  Therefore, we recommend that CMS: 
Take appropriate action on portable x-ray suppliers referred by the 
Office of Inspector General. 
Establish a process to periodically identify portable x-ray suppliers 
that merit greater scrutiny and follow up as appropriate. 
Determine what portion of the $12.8 million it paid for return trips in 
2009 actually reimbursed suppliers for incorrectly billed 
transportation component claims and collect overpayments where 
appropriate. 
Collect the $6.6 million in overpayments for portable x-ray services 
rendered in 2009 that were ordered by nonphysicians. 
Implement procedures to ensure that it pays for portable x-ray 
services only when ordered by a physician and establish 
appropriate controls. 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS concurred with our recommendations.  CMS stated that since the 
draft report was issued, it has embarked on a new fraud prevention 
initiative to help identify suspect fee-for-service claims, including the 
kinds of questionable billing described in this report.  CMS also stated 
that it is leveraging internal data and publicly available information to 
strengthen its provider-screening process.  CMS further indicated that it 
is revising the Medicare Benefit Policy Manual to be consistent with the 
regulations that would preclude Medicare from paying for portable x-ray 
services that are not ordered by a licensed medical doctor or doctor of 
osteopathy. 
For the full text of CMSs comments, see Appendix D. 
 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  iii   
 T A B L E   O F   C O N T E N T S  
EX ECUT I VE  SUM M ARY  .....................................i 
 
 
I NT RO DU CT I O N  ............................................ 1 
 
 
F I NDI NG S  .................................................  11 
Twenty portable x-ray suppliers exhibited questionable billing 
patterns ..............................................  11 
Medicare paid portable x-ray suppliers approximately                   
$12.8 million for return trips to nursing facilities .............  12 
Medicare paid at least $6.6 million for portable x-ray services         
that were ordered by nonphysicians and therefore not covered ..  12 
 
RECO M M END AT I O N S  ..................................     14 
  Agency Comments and Office of Inspector General Response . . . .  16 
 
APP EN DI X ES  .............................................  18 
A:  Detailed Methodology for Evaluating Questionable Claims       
     Patterns ............................................  18 
         B:  Distributions of Characteristics and Combined Score With  
     Related Thresholds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    22 
 
  C:  Billing Patterns of the 20 Selected Suppliers . . . . . . . . . . . . . .   23 
            D:  Agency Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    24 
 
 
ACKNO WL E DG M E N T S ..................................  .  28   I N T R O D U C T I O N  
OBJECTIVES 
1.  To identify portable x-ray suppliers with questionable billing 
patterns that may be associated with inappropriate Medicare 
payments.1 
2.  To identify claims for portable x-ray services that may warrant 
further review. 
BACKGROUND 
Medicare paid portable x-ray suppliers approximately $225 million 
under the Part B benefit for x-rays rendered in 2009.  Portable x-ray 
suppliers provide diagnostic imaging services at patients locations
most often residences, including private homes and group living 
facilities, such as nursing homesrather than in a traditional clinical 
setting, such as a doctors office or hospital.  The supplier transports 
mobile diagnostic imaging equipment to the patients location, sets up 
the equipment, and administers the test onsite.  The supplier may 
interpret the results itself or it may provide the results to an outside 
physician for interpretation. 
Only 20 percent of 2009 Medicare payments to portable x-ray suppliers, 
$44 million, was for administering the test and interpreting the results, 
services for which portable suppliers are paid the same rates as 
stationary x-ray providers.  The remaining 80 percent, $181 million, 
reimbursed suppliers for transporting the equipment to the beneficiarys 
location and setting it up for use (see Figure 1).  On average, Medicare 
paid approximately $17 for administration and interpretation and $80 
for transportation and setup of each portable x-ray in 2009, a 
substantial premium over the cost of the stationary service.  
Nevertheless, to the extent beneficiaries would otherwise require 
medical transportation to a stationary x-ray provider, portable x-rays 
may represent a cost savings to Medicare.  If a portable x-ray patient 
had qualified for and received nonemergency ambulance transportation 
to a stationary provider instead of receiving the portable service, 
 
1 Payments (also known as reimbursed amounts) refer to the amount paid for a covered 
service after the deductible and coinsurance amounts have been deducted.  Centers for 
Medicare & Medicaid (CMS), Glossary.  Accessed at 
http://www.cms.gov/apps/glossary/search.asp?Term=payment&Language=English on     
May 16, 2011. 
 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  1  I N T R O D U C T I O N  
Medicare would have paid the same $17 to the stationary provider for 
administration and interpretation, but $119 (on average) to the 
ambulance company for transportation.2 
FIGURE 1    2009 Payments to Portable X-ray Suppliers for X-rays, 
by Component 
 
Most payments to 
portable x-ray   
suppliers are for   
transporting the   
Administration and 
equipment. 
  interpretation 
20% 
 
 
 
Setup of equipment 
  10% 
Transportation of 
equipment 
70% 
  Source:  Office of Inspector General (OIG) analysis of 2009 Medicare National Claims History weekly carrier data, 
2011. 
Medicare coverage of portable x-ray services is governed by Federal 
laws and regulations and CMS policy.  The Code of Federal Regulations 
(CFR) provides licensing, registration, staffing, and safety requirements 
for portable x-ray suppliers.3  In particular, 42 CFR  486.106 requires 
that portable x-rays be ordered by a physician, defined by that 
regulation as a licensed medical doctor (MD) or doctor of osteopathy 
(DO).  The order must specify, in writing, both the reason for the x-ray 
service and the need for portable services.  Portable x-rays, like all 
diagnostic tests, also must be ordered by the physician who is treating 
the beneficiary ... and who uses the results in the management of the 
beneficiarys specific medical problem.4  The Medicare Benefit Policy 
Manual limits reimbursable portable x-rays to those of the extremities, 
pelvis, spine, skull, chest, and abdomen (collectively referred to 
hereafter as covered x-rays).5  Portable x-ray suppliers may also 
 
2 OIG analysis of 2009 Medicare National Claims History weekly carrier data, 2010. 
3 Applicable regulations are found at 42 CFR  486.100 through 42 CFR  486.110. 
4 42 CFR  410.32(a). 
5 CMS, Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15,  80.4.3. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  2  I N T R O D U C T I O N  
furnish electrocardiograms and mammograms,6 though these services 
accounted for less than 1 percent of portable suppliers Medicare 
payments for services rendered in 2009.7 
Billing Procedures for Portable X-Ray Services 
The Medicare Claims Processing Manual separates portable x-rays into 
as many as four components for billing and payment purposes.8  As with 
all diagnostic imaging tests, Medicare pays separately for administering 
the portable x-ray (the technical component) and interpreting the 
results (the professional component).  For portable x-rays, Medicare also 
pays separately for bringing the equipment to the beneficiarys location 
(the transportation component) and preparing it for use (the setup 
component). 
Portable x-ray suppliers bill the technical and professional components 
in the same manner as other diagnostic imaging providers.  To bill for 
the professional or technical component, the supplier submits a billing 
code to Medicare that identifies the test along with a modifier that 
specifies which component was furnished (modifier TC for the technical 
component or modifier 26 for the professional component).9  If the 
supplier furnishes both the technical and professional components 
(referred to as a global service), it submits a code with neither 
modifier.10 
The setup and transportation components pertain solely to portable 
services.  To bill for the setup component, the supplier submits one unit 
of billing code Q0092 for each imaging procedure furnished to the 
beneficiary (e.g., if the supplier furnishes a chest x-ray and a wrist       
x-ray, the supplier bills two units of Q0092).11  To bill for the 
transportation component, the supplier submits a billing code and 
modifier that, taken together, specify the number of patients to whom 
the supplier furnished a portable x-ray during a single trip to a 
particular location.  If the supplier used the equipment for one patient 
during the trip, the supplier bills code R0070 for the transportation 
component.  If the supplier used the equipment for more than one 
 
6 CMS, Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15,  80.4.3 and 80.4.5. 
7 OIG analysis of 2009 Medicare National Claims History weekly carrier data, 2010. 
8 CMS, Medicare Claims Processing Manual, Pub. No. 100-04, ch. 13,  90. 
9 CMS, Medicare Claims Processing Manual, Pub. No. 100-04, ch. 23, Addendum  
MPFSDB Record Layouts, 2008 File Layout and 2009 File Layout, Field #5. 
10 Ibid. 
11 CMS, Medicare Claims Processing Manual, Pub. No. 100-04, ch.13,  90.4. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  3  I N T R O D U C T I O N  
patient during the trip, it bills code R0075 for each patient.  The 
supplier also attaches a modifier that further specifies the total number 
of patients seen at the location during the trip (modifier UN, UP, UQ, 
UR, or US for two, three, four, five, or six or more patients, 
respectively).12 
No modifier or code exists to indicate when a supplier makes a return 
trip to a particular location on a given day, which creates ambiguity in 
the claims data.  For example, a supplier might bill R0070 for each of 
two beneficiaries known to be at the same location on a given day.  This 
could represent the correct billing of the transportation component for 
two separate trips to that location or the miscoding of a single trip 
during which the supplier saw both beneficiaries. 
Payment for Portable X-Ray Services 
The Medicare Physician Fee Schedule establishes payment rates for the 
technical and professional components of diagnostic imaging services.  
Medicare pays portable x-ray suppliers the same rates for these 
components as it does other diagnostic imaging providers.  The fee 
schedule also establishes the payment rate for the setup component.  
Each Medicare claims payment contractor determines the 
transportation component rate for its jurisdiction based on instructions 
in the Medicare Claims Processing Manual. 
Medicare pays each jurisdictions full transportation rate for R0070 and 
a prorated portion of the full rate for R0075 based on the modifier 
submitted.  For example, Medicare pays one-fourth the full rate for each 
instance of R0075 with modifier UQ (four patients).  As shown in     
Table 1, Medicare pays more for the transportation and setup 
components than it does for the professional and technical components 
of any of the three diagnostic imaging tests for which portable x-ray 
suppliers most commonly bill.13  This difference is most substantial 
when a portable x-ray supplier sees only one patient during a trip to a 
location.  In that case, Medicare pays at least four times as much for the 
transportation and setup of the equipment as it does for the technical 
and professional components combined. 
 
12 If a supplier sees more than six patients in a single trip to a location, it bills R0075 
with the US modifier for each patient, regardless of the actual number of patients seen.  
CMS, Medicare Claims Processing Manual, Pub. No. 100-04, ch.13,  90.3. 
13 The three x-ray billing codes displayed accounted for approximately 53 percent of the 
total amount that portable x-ray suppliers billed for covered x-rays in 2009. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  4  I N T R O D U C T I O N  
TABLE 1 
Payment Rates for Common Portable X-Ray Services 
Billing  2009 Payment 
Service Description  Code  Modifier  Rate* 
Chest x-ray; single view,  Technical Component (TC)  $14.79 
71010 
frontal  Professional Component (26)  $  9.02 
Chest x-ray; two views,  TC  $20.56 
71020 
frontal and lateral  26  $11.18 
Hip x-ray; complete,  TC  $25.25 
73510 
minimum two views  26  $10.82 
Setup component  Q0092  -  $16.23 
Transportation component; 
R0070  -  $145.41 
one patient 
UN (2 patients)  $72.71 
UP (3 patients)  $48.47 
Transportation component; 
R0075  UQ (4 patients)  $36.35 
multiple patients 
UR (5 patients)  $29.08 
US (6 or more patients)  $24.24 
Source:  Medicare Physician Fee Schedule, 2009, and OIG analysis of 2009 Medicare National Claims History 
Carrier Claims File, 2010. 
*The payment rates displayed for the x-rays and setup components are the physician fee schedule national 
payment amounts for 2009.  The payment rates displayed for the transportation component are the median 
2009 allowed amounts. 
Additional Background 
This study was conducted as part of the Health Care Fraud 
Prevention and Enforcement Action Team (HEAT) initiative, which 
focuses on reducing health care fraud through the use of innovative 
data analysis and enhanced cooperation between the Department of 
Justice (DOJ), Department of Health and Human Services (HHS) 
OIG, and CMS.14 
 
METHODOLOGY 
To meet our objectives, we used the Medicare National Claims History 
weekly carrier data (hereafter, Part B data); nursing home stay 
information in the Minimum Data Set (MDS); and Medicare Skilled 
Nursing Facility (SNF), Inpatient, Outpatient, Hospice, and Durable 
Medical Equipment (DME) National Claims History Standard Analytic  
   
 
14 DOJ and HHS, HEAT Task Force Success.  Accessed at  
http://www.stopmedicarefraud.gov/heatsuccess/index.html on January 19, 2011. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  5  I N T R O D U C T I O N  
File data for services rendered in 2008 and 2009.15  We also used 
National Plan and Provider Enumeration System (NPPES) data, which 
link Medicare providers names, addresses, and other information to 
their National Provider Identifiers (NPI), to identify the suppliers and 
ordering entities reported on claims. 
To focus on suppliers that regularly billed Medicare for portable x-ray 
services, we used the following process to define our study population.  
First, we identified all 2009 Part B claims billed with specialty code 63, 
which identifies the service provider as a portable x-ray supplier.  There 
were 521 such suppliers in this set of claims.  Next, we identified all 
claims from these suppliers for covered x-rays by examining the billing 
codes on the claims.  We then identified all claims for the transportation 
or setup components billed by the same supplier for the same 
beneficiary on the same day as a covered x-ray.  Lastly, we summarized 
these transportation and setup component claims by supplier to 
determine the amount that each supplier billed for these components for 
a covered x-ray.  We selected the 352 suppliers that billed at least 
$1,000 for the transportation and setup components to be our 
population. 
We used the claims data to calculate eight characteristics that represent 
questionable claims patterns for each supplier.  Based on conversations 
with CMS staff and OIG investigators, prior experience in other 
payment areas, and our own professional judgment, we determined that 
these characteristics may be associated with inappropriate Medicare 
payments for portable x-rays.  The characteristics generally reflected 
situations that occurred rarely in the population, but, with one 
exception (portable services ordered by nonphysicians), were not 
necessarily inappropriate.  Analysis of these characteristics are meant 
to identify suppliers that merit greater scrutiny, not to provide 
conclusive evidence of improper payments.  The eight characteristics are 
briefly described below; Appendix A provides a full description of all 
characteristics and the process for selecting them. 
 Portable services ordered by nonphysicians.  This characteristic 
o
represents the percentage of each suppliers charges for portable 
 
15 At the time we conducted our analysis, claims received through March 24, 2010, were 
the most recent available.  These claims represent approximately 98 percent of the total 
payments made through December 2010 to portable x-ray suppliers for services rendered in 
2009. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  6  I N T R O D U C T I O N  
services that was ordered by entities that lack MD or DO 
credentials.  Federal regulations require that Medicare portable     
x-ray services be ordered by a licensed MD or a licensed DO. 
 No recent contact between beneficiary and ordering provider.  This 
o
characteristic represents the percentage of each suppliers charges 
that was for a service when the beneficiary had not seen the 
ordering provider within 6 weeks prior to the service.  By 
regulation, all diagnostic tests must be ordered by the physician 
treating the beneficiary and the results must be used by the 
ordering physician to treat a specific medical problem.16   We expect 
that a claim for service from the ordering provider would generally 
precede the portable x-ray by a reasonably short periodwe used   
6 weeks to be conservative.  Additionally, prior OIG work has 
shown that apparent lack of contact between an ordering provider 
and the beneficiary may predict improper activity in other benefit 
areas. 
 Same-day services in multiple settings.  This characteristic 
o
represents the percentage of each suppliers portable services that 
occurred on a day on which the beneficiary also had services in a 
clinical setting (e.g., office or hospital).  Pursuant to Federal 
regulations, a beneficiary must have a specific need for portable 
services documented by the ordering physician.17  Logically, if the 
beneficiary received services in a clinical setting on a particular 
day, the need for portable services is less clear than if all services 
on that day were rendered at the beneficiarys location.  We 
excluded claims for services and items for which the beneficiary is 
not normally physically present at the place of service (e.g., 
laboratory services) from this analysis. 
 Billing for return trips.  This characteristic represents the percentage 
o
of each suppliers Medicare payments related to transportation 
component claims that appear to be billed for a trip to a facility 
already visited that day.  While a supplier may legitimately make 
multiple trips to a facility, it is also financially advantageous for the 
supplier to see all beneficiaries at a location in a single trip, but bill 
as if it made a separate trip for each.  Additionally, a supplier that 
 
16 42 CFR  410.32. 
17 42 CFR  486.106. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  7  I N T R O D U C T I O N  
submitted fictitious claims using fraudulently acquired beneficiary 
numbers might be unaware that the beneficiaries were collocated. 
 Portable x-rays per beneficiary.  This characteristic represents the 
o
average number of covered x-rays each supplier billed for its 
beneficiaries in 2009.  Suppliers that submit an unusually large 
number of x-rays compared to the number submitted by their peers 
could be billing for medically unnecessary tests or services not 
rendered. 
 Beneficiary contact with multiple portable suppliers.  This 
o
characteristic represents the percentage of each suppliers 
beneficiaries who also appeared on claims from another portable    
x-ray supplier in 2009.  Preliminary data analysis showed that few 
beneficiaries received portable services from more than one 
supplier.  Therefore, a large percentage with this characteristic may 
signify inappropriate patient sharing. 
 Beneficiary use of stationary x-ray services.  This characteristic 
o
represents the percentage of beneficiaries who received frequent     
x-rays from both portable x-ray suppliers and stationary providers 
in 2009.  First, we identified the 10 covered x-ray codes most 
frequently billed by portable x-ray suppliers as a whole.  These 10 
services accounted for 75 percent of the total allowed charges for    
x-rays from suppliers in our population in 2009.  We then 
determined the percentage of each portable x-ray suppliers 
beneficiaries for whom both the supplier and a stationary x-ray 
provider submitted a claim for any of these services.  If a large 
percentage of a portable suppliers beneficiaries also get stationary 
services, it may indicate that the supplier is billing for medically 
unnecessary services or services not rendered. 
 Beneficiary DME utilization.  This characteristic represents the 
o
average amount billed in 2009 for any DME item by any entity for 
each beneficiary of a portable x-ray supplier.  DME is a frequently 
abused benefit, and if a suppliers beneficiaries receive unusually 
large amounts of DME compared to those of other suppliers, it could 
indicate that the supplier is billing using compromised beneficiary 
numbers. 
We used these eight characteristics to evaluate suppliers billing 
patterns.  First, we analyzed the distribution of each characteristic to 
establish thresholds that signify questionable billing.  Next, we 
determined the number of characteristics on which each supplier 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  8  I N T R O D U C T I O N  
surpassed the related threshold.  Then we combined the eight 
characteristics to create a score for each supplier that we used to 
compare suppliers overall patterns of questionable billing (referred to 
hereinafter as the combined score).  We analyzed the distribution of the 
combined score to establish a questionable threshold in the same 
manner as for the individual characteristics.  Finally, to focus on the 
suppliers most likely to be associated with inappropriate payments, we 
set criteria to identify suppliers that exhibited questionable billing 
patterns.  To be selected, a supplier had to exceed thresholds for at least 
two individual characteristics and the threshold on the combined score.  
In addition to evaluating the supplier-level characteristics, we 
conducted two related analyses of claims for portable x-ray services as 
a whole to identify individual claims that may warrant further 
review.  First, we matched the Part B data to the NPPES data to 
determine the credentials of the ordering provider on each claim and 
then calculated the amount Medicare paid for services ordered by 
nonphysicians.  The methodology for this analysis was identical to 
that for the characteristic Portable services ordered by 
nonphysicians, except that we applied it to the entire set of claims 
billed by suppliers in our population. 
Second, we applied the methodology we used for the characteristic 
Billing for return trips to claims from our entire population to 
determine the total amount Medicare paid portable x-ray suppliers for 
return trips.  That is, we matched the Part B and MDS data to 
identify the nursing facility, if any, where each beneficiary was 
located on the day of the service.18  We then determined the number 
of trips the supplier appeared to have made to each facility each day 
based on the codes and modifiers used to bill for the transportation 
component for beneficiaries located at that facility.  For example, if a 
supplier billed R0070 for two patients located in the same facility, we 
determined the supplier made two trips to that facility.  Then we 
calculated the total amount Medicare paid for return trips to a 
facility. 
   
 
18 If the portable x-ray service fell on the first or last day of a nursing facility stay, we 
considered the beneficiary to not be in a nursing facility that day. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  9  I N T R O D U C T I O N  
Limitations 
We did not independently verify the accuracy of the data we used for 
this study; therefore, the accuracy of our findings is limited by the 
accuracy of the data.  With the exception of portable services ordered by 
nonphysicians, none of the characteristics we analyzed necessarily 
implies that a particular claim is inappropriate or that a particular 
supplier submitted inappropriate claims.  We designed this study to 
identify suppliers that merit greater scrutiny, not to provide conclusive 
evidence of improper payments.  
A portion of our analysis focuses on the ordering NPIs reported on 
claims submitted by portable x-ray suppliers.  In an October 15, 2008, 
program transmittal, CMS instructed suppliers to use their own NPIs 
as the ordering NPIs on Medicare claims if they cannot determine the 
NPIs of the ordering providers.19  Therefore, we cannot determine 
whether claims that report the suppliers own NPIs in the ordering NPI 
field represent services ordered by nonphysicians.  Instead, we 
specifically report on the incidence of suppliers using their own NPIs in 
the ordering field in the findings.  According to a CMS Transmittal, 
Medicare contractors were to stop paying claims that lack a valid NPI 
for the ordering provider on July 5, 2011.20  The transmittal also 
indicated that the date was subject to change.  CMS recently stated that 
it anticipates implementing edits in early 2012 to stop payment for 
claims that lack a valid NPI.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation approved by the Council of the Inspectors 
General on Integrity and Efficiency. 
 
19 CMS, Transmittal 270, Change Request 6093, October 15, 2008. 
20 CMS, Transmittal 825, Change Request 6417, December 16, 2010. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  10   F I N D I N G S  
Twenty portable x-ray suppliers exhibited  Most suppliers rarely billed for the 
questionable billing patterns  unusual situations described by the 
characteristics in our methodology, 
but 20 of the 352 in our population (5.7 percent) met our criteria for 
identifying questionable billing patterns.  That is, 20 suppliers exceeded 
thresholds for questionable billing on at least 2 individual 
characteristics and the threshold on the combined score, which 
describes suppliers overall billing patterns.  As shown in Table 2, 12 of 
the 20 suppliers exceeded thresholds on 4 or 
Table 2 : 
more characteristics.  The characteristics on 
Count of Suppliers That 
which the 20 suppliers most often exceeded  Exceeded Exact Number 
of Thresholds for 
thresholds were those that measured 
Individual Characteristics 
beneficiary use of stationary x-ray services 
Number of  Supplier 
(16 suppliers exceeded this threshold),  Thresholds  Count 
2  5 
same-day services in multiple settings      
3  3 
(16 suppliers), beneficiary contact with 
4  4 
multiple portable suppliers (15 suppliers),  5  7 
and beneficiary DME utilization                 6  1 
(13 suppliers).  Collectively, Medicare paid  Source:  OIG analysis of 2008 and 
the selected suppliers approximately        2009 Medicare and NPPES data, 
2011. 
$5.2 million for portable services rendered 
in 2009.  Appendix B provides for more information on how the supplier 
population performed on each characteristic.  Appendix C displays 
detailed information about each of the 20 suppliers that met our criteria 
for questionable billing. 
The supplier with the most questionable billing pattern had the highest 
combined score and exceeded thresholds on six individual 
characteristics.  Furthermore, the supplier ranked in the top 10 on the 
following 4 characteristics: 
  Services ordered by nonphysicians accounted for 30 percent of 
the charges for portable services this supplier submitted, 
compared to the median value of 1.1 percent for suppliers in the 
population. 
  The supplier billed 53 percent of its portable services on a day 
when the beneficiary had a service in a clinical setting (median 
value 6 percent). 
  In addition, 55 percent of the suppliers patients got services 
from at least one other portable x-ray supplier (median value   
9.9 percent). 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  11  F I N D I N G S  
  The suppliers patients had an average of $7,970 billed on their 
behalf for DME in 2009 (median value $3,198). 
As a group, the 20 suppliers who met our criteria had several additional 
features that differentiated them from suppliers with more typical 
billing patterns.  First, only 9 percent of the payments to selected 
suppliers were associated with services billed for beneficiaries in a 
nursing facility at the time of service, compared to 73 percent of the 
payments to other suppliers.  Second, 13 of the selected suppliers were 
located in the Miami, Florida, area, more than half the total                 
25 suppliers in our population with addresses there.  All 13 Miami 
suppliers surpassed thresholds on at least 3 characteristics, compared 
to only 2 of the 7 suppliers from outside the Miami area that met our 
criteria. 
 
Medicare paid portable x-ray suppliers  Medicare paid suppliers 
approximately $12.8 million for return trips to  approximately $108 million for 
transportation component claims 
nursing facilities 
for portable x-rays furnished in 
2009 while the beneficiary was in a nursing home or SNFs, according to 
MDS data.  Approximately 12 percent of this amount, $12.8 million, was 
for trips to a location apparently already visited on the same day.  As a 
typical example, one supplier submitted two separate claims for 
transportation costs (R0070), one for each of two beneficiaries, on a 
particular day.  Medicare paid each claim at the full transportation 
component rate.  However, MDS data show that these two beneficiaries 
were located in the same nursing home on that date.  Claims data do 
not provide sufficient information to determine whether the supplier 
billed correctly for two separate trips to the facility or administered 
tests to the two beneficiaries during a single trip and failed to use the 
appropriate prorated billing code.   
 
Medicare paid at least $6.6 million for portable  Contrary to 42 CFR  486.106, 
x-ray services that were ordered by  which requires that portable     
x-rays be ordered by an MD or 
nonphysicians and therefore not covered 
DO,  Medicare paid $6.6 million 
for portable x-ray services ordered by nonphysicians in 2009.  Nurse 
practitioners ordered services that accounted for $4.3 million of this 
amount.  Physician assistants and podiatrists ordered approximately  
$1 million and $900,000, respectively.  Various other medical 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  12  F I N D I N G S  
professionals, such as registered nurses and chiropractors, accounted for 
the remaining $400,000. 
Medicare paid an additional $5.9 million for services for which we could 
not determine whether the ordering provider possessed appropriate 
credentials.  The ordering NPIs on claims that generated $1.2 million of 
this amount did not match a current record in the NPPES data or 
identified a group practice, not an individual practitioner.  Additionally, 
about $4.6 million of the $5.9 million for services went to suppliers that 
reported their NPIs as the ordering NPIs on the claims.21  This amount 
included $3.1 million that went to one supplier that reported its own 
NPI on nearly 100 percent of its portable x-ray claims and $842,000 for 
three suppliers that used their own NPIs on claims that accounted for at 
least 20 percent of their Medicare payments.    
 
21 Because of rounding, the sum of the paid amounts shown for the subcategories does 
not equal the total paid amount shown for services for which we could not determine 
whether the ordering providers possessed appropriate credentials. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  13   R E C O M M E N D A T I O N S  
Portable x-rays constitute a small portion of overall Medicare payments 
for diagnostic imaging services, but the questionable claims patterns we 
found raise concerns about the integrity of payments to certain portable 
x-ray suppliers.  Furthermore, payments for portable services ordered 
by nonphysicians clearly violate Federal regulations and should be 
recovered.  Lastly, payments for return trips to facilities, while not 
necessarily inappropriate, may represent an additional opportunity for 
program savings.  Therefore, we recommend that CMS: 
Take appropriate action on portable x-ray suppliers referred by the Office of 
Inspector General 
OIG is currently determining what, if any, OIG enforcement action it 
should take on the 20 suppliers we identified with questionable billing 
patterns and the 4 suppliers that derived more than 20 percent of their 
Medicare payments from claims on which the suppliers reported their  
own NPIs as the ordering NPIs.  After we complete our internal process, 
we will provide CMS (under separate cover) the identities of those 
suppliers against which we believe it would be appropriate for CMS to 
take administrative action. 
Establish a process to periodically identify portable x-ray suppliers that 
merit greater scrutiny and follow up as appropriate  
Although our methodology cannot positively identify suppliers that have 
received inappropriate Medicare payments, we identified some suppliers 
with questionable claims patterns that merit greater scrutiny.  CMS 
should establish a process to identify portable x-ray suppliers that 
present a likely risk to the program and refer them for appropriate 
administrative or enforcement action.  We leave the details of such a 
process to CMSs discretion, but as CMS has access to all the data 
sources we used for our analysis, it could use the methodology in this 
report as a guide.  Given the preponderance of Miami suppliers among 
those we identified with questionable billing, CMS may initially wish to 
focus on Miami and later expand to other high-risk jurisdictions. 
Determine what portion of the $12.8 million it paid for return trips in         
2009 actually reimbursed suppliers for incorrectly billed transportation 
component claims and collect overpayments where appropriate 
Medicare paid portable x-ray suppliers $12.8 million for apparent 
return trips to nursing facilities in 2009, but some portion of this 
amount may be attributable to incorrectly billed transportation 
component claims.  That is, the supplier may have obtained excess 
reimbursement by billing as if it made multiple trips to a facility when, 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  14  R E C O M M E N D A T I O N S  
in fact, it saw all beneficiaries located in that facility in a single trip.  
CMS should instruct its contractors to conduct a focused medical review 
on a sample of these claims to identify any overpayments and determine 
the extent of errors of this type.  Depending on the results of this 
preliminary review, CMS may wish to initiate more extensive reviews of 
such claims on a regular basis.  CMS should also recover any 
overpayments discovered in the preliminary or more extensive review  
(if conducted). 
Collect the $6.6 million in overpayments for portable x-ray services rendered 
in 2009 that were ordered by nonphysicians 
Federal regulations at 42 CFR  410.32(a) and 486.106 clearly state 
that portable x-ray services must be ordered by an MD or a DO to be 
eligible for Medicare reimbursement.  Therefore, CMS should instruct 
its contractors to collect overpayments on the $6.6 million paid for 
portable x-ray services ordered by nonphysicians.  Under separate 
cover, we will provide CMS the information needed to identify these 
claims. 
Implement procedures to ensure that it pays for portable x-ray services only 
when ordered by a physician and establish appropriate controls 
CMS should weigh the costs and benefits of prepayment and 
postpayment controls to ensure that portable x-ray services meet the 
requirement established in 42 CFR  410.32(a) and 486.106 concerning 
the credentials of the ordering provider.  Depending on the results of the 
analysis, CMS could instruct its contractors to verify that the ordering 
NPI on each claim for portable x-ray services identifies an MD or a DO 
before paying the claim.  Alternatively, CMS could instruct its 
contractors to periodically review paid portable x-ray claims to verify 
the credentials of the ordering providers and collect overpayments 
where appropriate.  CMS may explore other options at its discretion. 
As part of its response to this recommendation, CMS should fully 
implement the requirement, though not specific to portable x-ray 
services, that claims for services requiring the supplier to report an 
ordering provider bear the correct NPI of that ordering provider.  This 
action should eliminate payments for services for which the credentials  
   
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  15  R E C O M M E N D A T I O N S  
of the ordering entity cannot be determined (for which CMS paid $5.9 
million in 2009).  OIG made a similar recommendation in a February 
2009 report.22  
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS concurred with our recommendations.  CMS stated that since the 
draft report was issued, it has embarked on a new Fraud Prevention 
System to help identify suspect fee-for-service claims, including the kinds 
of questionable billing described in this report.  CMS also stated that it is 
leveraging internal data and publicly available information to strengthen 
its provider-screening process which will help keep portable x-ray 
providers that have exhibited suspicious or fraudulent behaviors from 
reenrolling in Medicare.  CMS further indicated that it is revising the 
Medicare Benefit Policy Manual to be consistent with the regulations that 
would preclude Medicare from paying for portable x-ray services that are 
not ordered by an MD or a DO. 
Specifically, in response to our first recommendation, CMS concurred and 
stated that after it receives and reviews the necessary information about 
the suppliers and claims discussed in this report, it will take the 
appropriate administrative action. 
In response to our second recommendation, CMS concurred and stated 
that it implemented a new Fraud Prevention System to detect potential 
fraud and abuse by suppliers of portable x-ray services.  CMS also stated 
that it will perform periodic analyses on suppliers and will explore 
opportunities to build reliable models that can detect and generate alerts 
for suspicious activity. 
In response to our third recommendation, CMS concurred but stated that 
because of limited resources and timing, it cannot initiate a review of a 
sample of portable x-ray claims at this time.  Instead, CMS stated that it 
would forward the list of questionable claims to the appropriate 
contractor for further consideration.   
In response to our fourth recommendation, CMS concurred and stated 
that it plans to recover the $6.6 million in overpayments identified. 
 
22 OIG, Medicare Payments in 2007 for Medical Equipment and Supply Claims With 
Invalid or Inactive Referring Physician Identifiers, OEI-04-08-00470. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  16  In response to our fifth recommendation, CMS concurred and stated it is 
revising the Medicare Benefit Policy Manual to be consistent with the 
regulations that would preclude Medicare from paying portable x-rays 
that are not ordered by an MD or a DO.   
For the full text of CMSs comments, see Appendix D. 
 
 
 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  17   A P P E N D I X   ~   A  
Detailed Methodology for Evaluating Questionable Claims Patterns 
Our first step in evaluating the billing patterns of portable x-ray 
suppliers was to identify potential indicators of inappropriate payments.  
Based on conversations with Centers for Medicare & Medicaid Services 
staff and Office of Inspector General investigators, prior experience in 
other payment areas, and our own professional judgment, we developed 
an initial set of 16 indicators that could potentially meet this goal.  
These indicators were based either on characteristics of individual 
claims (e.g., the percentage of portable services ordered by 
nonphysicians) or on the claims histories of beneficiaries (e.g., the 
average number of portable imaging services per beneficiary). 
After identifying the initial set of potential indicators, we then 
calculated each indicator for each supplier and examined the 
distribution of values across suppliers.  If a distribution showed that 
most suppliers had relatively low values for an indicator, but a small 
number had distinctly higher values, we determined that, for this 
indicator, a suppliers deviation from the population was likely to be 
meaningful.  Eight indicators met this criterion; these became the eight 
characteristics we chose to represent questionable billing patterns of 
suppliers.  The specific methodologies we used to calculate each of the 
eight characteristics are described below. 
  Portable services ordered by nonphysicians.  We first matched the 
o
ordering National Provider Identifier (NPI) on each claim to 
National Plan and Provider Enumeration System (NPPES) data to 
identify the ordering provider.  We then used two data elements 
from the NPPESthe primary taxonomy code (a self-selected code 
that captures the providers primary area of expertise) and the 
credentialsto determine whether the entity was a licensed 
physician.  If the entitys primary taxonomy code corresponded to a 
physician specialty or the entity listed medical doctor (MD) or doctor 
of osteopathy (DO) credentials, we considered the ordering provider 
to be a physician.  Failing that, if the primary taxonomy code 
indicated that the ordering provider was a group practice, the 
ordering NPI did not match a record in the NPPES or was missing, 
or the supplier reported its own NPI in the ordering field, we 
considered the credentials of the entity to be unknowable.  
Otherwise, we considered the ordering provider to be a 
nonphysician.  We verified that a random sample of 10 nonphysician 
ordering entities identified through this process did not hold MD or 
DO credentials by searching State medical licensure Web sites by 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  18  A P P E N D I X   ~   A  
the name and State of the entity.  We then calculated the percentage 
of each suppliers submitted charges that were derived from claims 
ordered by nonphysicians.  We limited this analysis to claims for 
services rendered on the same day and for the same beneficiary as a 
claim for the transportation or setup component to ensure that we 
included only services subject to 42 CFR  486.106, which requires 
that portable services be ordered by a physician. 
  No recent contact between beneficiary and ordering provider.  We first 
o
excluded claims on which the suppliers reported their own NPIs as 
the ordering NPI.  We then identified each unique combination of 
beneficiary, ordering provider, and service date among claims 
submitted by portable x-ray suppliers in our population.  We then 
determined whether the ordering NPI appeared as the performing, 
attending, operating, or other NPI on a claim for Part B, Skilled 
Nursing Facility (SNF), Inpatient, Outpatient, or Hospice claim with 
a service date 6 weeks or less prior to the portable x-ray service.  If 
so, we determined that the beneficiary and ordering provider had 
had recent contact.  Otherwise, we determined that the two did not 
have recent contact.  We then calculated the percentage of each 
suppliers charges submitted for claims with no evidence of recent 
contact between the beneficiary and ordering provider. 
  Same-day services in multiple settings.  We first created a dataset 
o
with 2009 Part B claims for all beneficiaries in our population.  We 
excluded claims for transportation services, tangible goods (e.g., 
parenteral nutrition supplies), pathology and laboratory services, 
the professional component of diagnostic services, and other services 
and items for which the beneficiary is not normally present at the 
place of service.  We then examined the place of service code on the 
claim to identify the setting in which the service was rendered.  If 
the place of service code corresponded to a physicians office, 
hospital, or medical clinic, we considered the setting to be clinical.  If 
the code corresponded to a homeless shelter, private home, nursing 
facility, hospice, or a residential treatment facility, we considered 
the setting to be residential.  If the beneficiary had a portable x-ray 
service in a residential setting on the same day as another service in 
a clinical setting, we determined that the beneficiary had services in 
multiple settings that day.  We then calculated the percentage of 
each suppliers beneficiary-service day combinations for which the 
beneficiary had services in multiple settings. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  19  A P P E N D I X   ~   A  
  Billing for return trips.  We matched our portable x-ray claims 
o
population to the Minimum Data Set and SNF stay data by 
beneficiary number and date to identify the facility, if any, where 
the beneficiary was located on the day of each transportation 
component service.  If the transportation component service fell on 
the first or last day of a nursing facility stay, we considered the 
beneficiary to not be in a facility.  Otherwise, we considered the 
beneficiary to be in the facility identified in the stay data.  We then 
grouped the transportation component claims that each supplier 
submitted for beneficiaries in each facility into trips according to the 
billing code on the claim.  For instance, if a supplier submitted two 
claims with the two-patient transportation component code and one 
with the one-patient code for three beneficiaries located in the same 
facility on a certain day, we would group these claims into two trips.  
We then assigned an order to the trips according to the amount 
Medicare paid for each, with the trip for which Medicare paid the 
most as the first trip.  Lastly, we determined the percentage of 
each suppliers total Medicare payments derived from transportation 
component claims for any trip beyond the first to a facility. 
  Portable x-rays per beneficiary.  We calculated the total number of 
o
covered x-rays billed by each portable x-ray supplier in 2009, 
excluding any tests for which the supplier billed only the 
professional component.  We then divided this total by the number 
of beneficiaries for whom each supplier submitted a claim to get the 
average number of portable x-rays per beneficiary for each supplier. 
  Beneficiary contact with multiple portable suppliers.  We counted the 
o
number of distinct portable x-ray suppliers that submitted a claim 
for each beneficiary in our population dataset.  We then determined 
the percentage of each suppliers beneficiaries that had claims from 
at least two portable suppliers in 2009. 
  Beneficiary use of stationary x-ray services.  First, we identified the         
o
10 billing codes for covered x-rays most commonly billed by portable 
x-ray suppliers in our population, weighted by allowed charges.  
These 10 codes constituted approximately 75 percent of the total 
allowed charges for x-rays in our population.  We then created a 
dataset containing all Part B claims for these codes for beneficiaries 
in our population, regardless of the specialty of the performing 
provider.  Finally, we calculated the percentage of each portable 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  20  A P P E N D I X   ~   A  
suppliers beneficiaries who also appeared on a claim for one of the 
codes from a stationary provider during 2009. 
  Beneficiary Durable Medical Equipment (DME) utilization.  From the 
o
2009 DME claims data, we calculated the amount billed for any 
DME item on behalf of each beneficiary in our population.  We then 
calculated the average amount of billed charges for DME per 
beneficiary who had at least one DME claim for each supplier in our 
population. 
After selecting the characteristics to use for our supplier profiles, we 
calculated thresholds for each characteristic to define questionable 
billing.  If the distribution of the characteristic was exponential, we set 
the threshold at the 90th percentile of the characteristic.  Otherwise, we 
set the threshold at a value where, after removing suppliers above the 
threshold, the remaining values formed an approximately normal 
distribution. 
We then combined the eight characteristics into an overall score, which 
we called the combined score.  We first determined the maximum value 
for each characteristic among the suppliers in our population.  We then 
divided each suppliers value for each characteristic by the maximum 
value for that characteristic to create a normalized score on a zero to 
one scale for each characteristic.  We then summed the normalized 
values for each characteristic to create the combined score.  We 
determined the threshold for the combined score in the same manner as 
for the individual characteristics.  Appendix B shows the median and 
maximum values for each characteristic and the combined score as well 
as the corresponding thresholds and the number of suppliers that 
exceeded each threshold. 
For example, the top supplier in our population had a value of 5.125 for 
the characteristic Portable x-rays per beneficiary.  Therefore, we 
divided each suppliers value for that characteristic by 5.125 to get each 
suppliers normalized score.  The top supplier had a normalized score of 
5.125 divided by 5.125, or 1.  Meanwhile, the supplier with the 
minimum value on that characteristic, 0.4444, had a normalized score of 
0.4444 divided by 5.125, which is 0.0867.  We performed this operation 
for each characteristic and then summed the normalized scores into the 
single combined score for each supplier.
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  21   A P P E N D I X   ~   B  
     
 
Distributions of Characteristics and Combined Score With Related 
Thresholds 
 
Median  Maximum  Suppliers 
Supplier  Supplier  Exceeding 
Characteristic  Detail  Value  Value  Threshold  Threshold 
Portable services  Amount billed for claims  1.09%  95.6%  14.1%  35 
ordered by  with characteristic as 
nonphysicians  percentage of total 
charges for portable 
services per supplier 
No recent contact  Amount billed for claims  30.7%  100%  55.0%  27 
between beneficiary  with characteristic as 
and ordering provider  percentage of total 
charges per supplier 
Same-day services in  Service days with  6.04%  80.7%  11.78%  35 
multiple settings  characteristic as 
percentage of total 
service days per supplier 
Billing for return trips  Transportation  4.55%  35.4%  11.4%  35 
component payments 
associated with return 
trips as percentage of 
total payments per 
supplier 
Portable x-rays per  Mean number of  2.11  5.13  3.00  10 
beneficiary  portable x-rays per 
beneficiary per supplier 
Beneficiary contact  Percentage of each  9.88%  100%  30.7%  35 
with multiple portable  suppliers beneficiaries 
suppliers  that received services 
from at least one 
additional portable x-ray 
supplier 
Beneficiary use of  Percentage of each  11.1%  90.0%  20.8%  40 
stationary x-ray  suppliers beneficiaries 
services  that also received similar 
services from a 
stationary x-ray provider 
Beneficiary durable  Mean charges for DME  $3,198  $8,732  $5,200  32 
medical equipment  per beneficiary per 
(DME) utilization  supplier 
Combined score  -  1.66  3.73  2.37  22 
Source:  Office of Inspector General analysis of 2008 and 2009 Medicare and National Plan and Provider 
Enumeration System data, 2011. 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  22   A P P E N D I X   ~   B  
 
 A P P E N D I X   ~   C  
     
 
  Billing Patterns of the 20 Selected Suppliers   
 
  Characteristic 
No recent  Medicare 
contact  Beneficiary  payments 
Portable  between  Same-day  contact with  Beneficiary  Combined  for portable 
services  beneficiary  services in  Portable x- multiple  use of  Beneficiary  score  x-rays 
ordered by  and ordering  multiple  Billing for  rays per  portable  stationary      DME  (Threshold  rendered in 
Supplier  Location  nonphysicians  provider  settings  return trips  beneficiary  suppliers  x-ray services  utilization  =2.37)  2009 
A  Miami  X  X  X  -  -  X  X  X  3.73  $255,749 
B  Miami  -  X  X  -  -  X  X  X  3.28  $482,711 
C  Miami  -  X  X  -  -  X  X  X  3.40  $407,910 
D  Miami  -  X  X  -  -  X  X  X  3.16  $335,339 
E  Miami  -  X  X  -  -  X  X  X  3.07  $136,788 
F  Miami  -  X  X  -  X  X  X  -  2.97  $176,238 
G  Miami  X  -  X  -  -  X  X  X  3.62  $23,201 
H  Other  -  X  -  -  X  X  X  X  3.69  $3,955 
I  Miami  -  -  X  -  -  X  X  X  2.66  $592,970 
J  Miami  -  -  X  -  -  X  X  X  2.90  $407,114 
K  Miami  -  -  X  -  -  X  X  X  2.84  $224,860 
L  Other  X  X  X  -  -  -  -  X  3.30  $42,025 
M  Miami  -  -  X  -  -  X  X  -  2.39  $236,617 
N  Miami  -  -  X  -  -  X  X  -  2.62  $53,462 
O  Miami  -  -  -  -  -  X  X  X  2.61  $833,541 
P  Other  -  -  X  X  -  -  -  -  2.44  $519,355 
Q  Other  -  -  X  -  -  -  X  -  2.41  $226,036 
R  Other  -  -  X  -  -  -  -  X  2.37  $145,410 
S  Other  -  -  -  X  X  -  -  -  3.06  $85,456 
T  Other  -  -  -  -  -  X  X  -  2.56  $2,428 
Total    3  8  16  2  3  15  16  13  -  $5.2 million 
  Source:  Office of Inspector General analysis of 2008 and 2009 Medicare and National Plan and Provider Enumeration System data, 2011. 
OEI-12-10-00190           QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS            23  x 
A  P  PEN  D  D 

Agency Comments 
'~ 
(".... DEPAR1MENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
\~:5~ 
Administrator 
Washington. DC 20201 
DATE:  AUG  0 4 2Dll 
TO:  Daniel R. Levinson 
Inspector General 
FROM:  Donald M. Berwick, M.D. 
Administrator 
SUBJECT:  Office of Inspector General (OIG) Draft Report: "Questionable Billing Patterns 
of Portable X-Ray Suppliers" (OEI-12-10-00190) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the OIG draft report entitled "Questionable Billing Patterns ofPortable X-Ray 
Suppliers," (OEI-12-10-00190). The purpose ofthis report is two-fold. First, it seeks to identify 
portable x-ray suppliers with questionable billing patterns that may be associated with 
inappropriate Medicare payments. Secondly, it seeks to identify claims for portable x-ray 
services that may warrant further review. 
Portable x-ray suppliers provide diagnostic imaging services at patients' locations such as private 
homes and group living facilities, rather than in a traditional clinical setting, such as a doctor's 
office or hospital. As stated in the report portable x-rays constitute eight percent of the amount 
Medicare paid to portable suppliers in 2009 reimbursed them for transporting and setting up the 
equipment. According to the OIO's report, Medicare paid approximately $225 million under the 
Part B benefit in 2009 for x-rays of the extremities, pelvis, spine, skull, chest, and abdomen. 
However, we recognize that such questionable billing patterns raise legitimate concerns about 
potentially inappropriate Medicare payments and appreciate the OIG bringing this issue to our 
attention. Since the report was issued, CMS has embarked on a new fraud prevention initiative 
which will help eMS identify suspect fee-for-service claims, including the kinds ofquestionable 
billing described in this report. 
Launched on June 30, 2011, the eMS's new Fraud Prevention System (FPS) reviews every fee
for-service claim, including those submitted by portable x-ray suppliers, to identify claims and 
providers that merit greater scrutiny. The new system alerts eMS to unusual billing patterns and 
other suspicious behavior while simultaneously prioritizing claims so eMS can strategically 
target resources for additional review, investigation, and administrative action as necessary. 
eMS is now able to review claims, investigate providers, make referrals to law enforcement, and 
take administrative actions against providers more efficiently than before. eMS will perform 
analyses on portable x-ray suppliers and will explore opportunities to build reliable models that 
can detect and generate alerts for suspicious portable x-ray activity. 
OEI121000190  QUESTIONABLE BILLING PATTERNS OF PORTABLE XRAY SUPPLIERS  24  A P P E N D I X   ~   D  
   
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  25  A P P E N D I X   ~   D  
 
 
   
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  26  AA PP PP EE NN DD II XX    ~~    DD   
 
 
   
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  27   A C K N O W L E D G M E N T S  
 
 
This report was prepared under the direction of Dave Graf, Director, 
Technical Support Staff, in the Baltimore office.   
Scott Hutchison served as the team leader for this study.  Other 
principal Office of Evaluation and Inspections staff who contributed to 
the report include Berivan Demir Neubert, Rita Wurm, Scott Horning, 
and Robert Gibbons. 
 
  OEI-12-10-00190  QUESTIONABLE BILLING PATTERNS OF PORTABLE X-RAY SUPPLIERS  28   
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: 
Office of Audit Services 
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.  
Office of Investigations 
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 programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In 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 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.