Department of Health and Human Services
 

OFFICE OF 

INSPECTOR GENERAL 

PROVIDER RELATIONSHIPS 


AND THE USE OF 


MAGNETIC RESONANCE 


UNDER THE MEDICARE 


PHYSICIAN FEE SCHEDULE
 

Daniel R. Levinson
 

Inspector General 


September 2008
 

OEI-01-06-00261
 
 

 

 

 

 

 

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 OIG’s 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. 
 

Δ EXECUTIVE SUMMARY 

OBJECTIVE 

To determine (1) how magnetic resonance (MR) services paid under 

the Medicare Physician Fee Schedule (MPFS) are provided and 

(2) whether there is a relationship between utilization levels of 

services and how they are provided. 

BACKGROUND 

Previous Office of Inspector General work documented a more than 

fourfold increase in MR services paid under the MPFS between 1995 

and 2005. 

Medicare divides imaging services into two components: the technical 

component and the professional component. Medicare may pay 

separately for each or make a global payment to one provider as 

payment for both. In certain situations, providers may purchase either 

component and reassign their Medicare payments to other entities. 

Each MR service may involve several roles, including the orderer of the 

service, providers of the technical and professional components, the 

billing provider, the payee, and equipment lessors and coowners. Each 

role may be played by the same or multiple parties. When multiple 

parties work together to provide MR services, they may be connected to 

one another through medical practice relationships and/or other 

business relationships. 

This study relies on analysis of 2005 Medicare Part B claims data and 

projections of data from a sample of MR services. This study focuses on 

the provision of the technical component of MR services. It presents 

data about all MR services and two subgroups of MR services: (1) those 

ordered by high users of MR and (2) those in which the orderer of the 

service had a connection to one or more of the parties involved in 

providing the service (hereafter referred to as connected services). This 

study did not analyze the appropriateness or medical necessity of MR 

services. 

FINDINGS 

Certain characteristics were common to a majority of magnetic 

resonance services paid under the Medicare Physician Fee 

Schedule, regardless of whether they were ordered by high users. 

Although providers worked together to provide services in a number of 

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EXECUTIVE SUMMARY 
 

ways, certain characteristics were common to a majority of services. For 

example, two-thirds of services were ordered by one of four specialties: 

internal medicine, orthopedic surgery, family practice, and neurology. 

Eighty-five percent of services were performed by the entity that was paid 

by Medicare. Most services were performed by the independent 

diagnostic testing facility (IDTF), multispecialty group, and diagnostic 

radiology provider specialties. Finally, MR claims were typically billed 

globally through a radiologist and had payment reassigned. 

Connected services were provided differently than services that 

were not connected. One-quarter of MR services paid under the MPFS 

in 2005 were connected services, which were associated with high use. 

Compared to all other services, connected services were more likely to be 

ordered by orthopedic surgeons. Multispecialty groups performed and 

were paid for half of connected services, compared to only one-quarter of 

all other services. The IDTF and diagnostic radiology specialties played a 

smaller role in connected services compared to all other services. Finally, 

connected services were more likely than other services to have been 

billed as technical component only, to have had payment reassigned, and 

to have been billed through a provider other than a radiologist. 

CONCLUSION 

The findings in this report highlight the complex nature of how 

providers deliver MR paid under the MPFS. The large number of ways 

that various parties can perform and bill for services reduces the 

transparency of these transactions. Although the analysis in this report 

was limited to MR, it is possible that such complexity extends to other 

types of high-cost imaging paid under the MPFS. The complexity and 

limited transparency with which these services are provided warrants 

continued attention to ensure that services are reasonable, necessary, 

and compliant with Medicare statutes and regulations. 

AGENCY COMMENTS 

The Centers for Medicare & Medicaid Services (CMS) agreed with our 

findings and our conclusion that the complexity of MR services warrants 

continued attention. It outlined regulatory steps it has recently taken 

to address overutilization of diagnostic testing services. CMS also 

stated its commitment to examining the relationship between the 

utilization of advanced imaging services and the entities that order and 

bill for them. 

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Δ TABLE OF CONTENTS 

EXECUTIVE SUMMARY ..................................... i 
 

INTRODUCTION ........................................... 1 
 

KEY ANALYTIC CONCEPTS ............................... 7 
 

FINDINGS ................................................. 9 
 

Certain characteristics were common to a majority of magnetic 

resonance services, even those ordered by high users ........... 9 
 

Connected services were provided differently than

services that were not connected .......................... 11 
 

CONCLUSION ............................................ 14 
 

APPENDIXES ............................................. 15 
 

A: Methodology........................................ 15 
 

B: Magnetic Resonance Service Delivery Diagrams ........... 21 
 

C: Statistical Tables.................................... 55 
 

D: Agency Comments ................................... 57 
 

ACKNOWLEDGMENTS .................................... 59 
 
INTRODUCTION 

 

 

 

Δ INTRODUCTION 

 OEI-01-06-00261 

OBJECTIVE 

To determine (1) how magnetic resonance (MR) services paid under 

the Medicare Physician Fee Schedule (MPFS) are provided and 

(2) whether there is a relationship between utilization levels of 

services and how they are provided. 

BACKGROUND 

Previous Office of Inspector General (OIG) work documented a more 

than fourfold increase in MR services paid under the MPFS between 

1995 and 2005.1 By 2005, 43 percent of all Medicare-covered MR 

services were paid under the MPFS.2 

Overview of Magnetic Resonance 

MR enables doctors to diagnose and treat patients by providing 

detailed images of tissues and blood vessels deep inside the body. MR 

is used to detect a number of conditions, including cancer, heart 

disease, damage to bones and organs, and brain disorders. Advances 

in technology continue to expand the number of clinical applications 

for MR and increase its availability in ambulatory settings covered 

under the MPFS, such as doctors’ offices and imaging centers. 

Payment for Magnetic Resonance Services Under the Medicare Physician 

Fee Schedule 

Medicare covers MR as a diagnostic service under § 1861(s)(3) of the 

Social Security Act. Medicare generally covers specific imaging 

procedures if they are supported as efficacious in scientific literature 

and reasonable and necessary for the patient.3 

Medicare divides imaging services into two components: the technical 

component, which is the taking of the image, and the professional 

component, which is the doctor interpreting the image. Medicare may 

pay for the components separately, to different providers, or it may 

make a global payment to one provider as payment for both 

components, even when different providers perform the technical and 

1 OIG, “Growth in Advanced Imaging Paid Under the Medicare Physician Fee Schedule,” 

OEI-01-06-00260, October 2007.
 

2 The remaining 57 percent were covered under the Hospital Outpatient Prospective 

Payment System and the Hospital Inpatient Prospective Payment System. 

3 Centers for Medicare & Medicaid Services (CMS) “Medicare National Coverage
 

Determinations Manual,” Pub. No. 100-03 § 220.1. 

P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 1 
 

INTRODUCTION 
 

professional components.4 In 2005, the average allowed charge for 

the professional component of the most commonly performed service, 

MR imaging of the spine without dye, was $77. The average allowed 

charge for the technical component of the same service was $463 and 

for the global payment, $579. 

Medicare allows providers to purchase either component of MR services 

from other providers.5 Thus, a provider may pay another provider to 

perform the service and then bill Medicare as if it had performed the 

service itself. However, specific rules apply to how and when providers 

may bill Medicare for each component.6 

In certain situations, Medicare allows a doctor to reassign his or her 

Medicare payments to another entity.7 For example, a doctor might 

reassign payment for services performed to his or her group practice. 

Roles Involved in Providing Magnetic Resonance Services Under the 

Medicare Physician Fee Schedule 

Each MR service may involve a number of persons and entities playing 

different roles, which are defined in Table 1 below. 

Table 1: Roles Involved in Magnetic Resonance Services 

Orderer 

Performer 

Reader 

Biller 

Payee 

Lessor* 

Coowner* 

The doctor who orders the MR service, typically the doctor treating the 

patient 

The provider that performs the technical component by operating the MR 

machine that produces images for interpretation 

The doctor who provides the professional component by interpreting the 

images from the technical component performer 

The provider under whose provider number the claim for the service is 

submitted to Medicare 

The entity that receives payment from Medicare for the service 

An entity that provides leased MR equipment used for the service 

An entity that coowns MR equipment used for the service 

* Not necessarily involved in every MR service. 

4 For purposes of this document, we use the term “provider” to refer to Part B suppliers, 

which include doctors, group practices, imaging centers, and others. 

5 Social Security Act § 1842(n), 42 U.S.C. § 1395u(n)(2005). 

6 CMS “Medicare Claims Processing Manual,” Pub. No. 100-04, ch.1, § 30.2. 

7 Social Security Act § 1842(b)(6), 42 U.S.C. § 1395u(b)(6).
 

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INTRODUCTION 
 

These roles may be played by doctors, group practices, imaging 

centers, or other entities. In a given service episode, each role may be 

played by the same or multiple parties. 

Provider Relationships Involved in Magnetic Resonance Service Delivery 

When multiple parties are involved in a service episode, they may be 

connected to one another through medical practice relationships and/or 

other business relationships. 

For purposes of this report, a medical practice relationship exists when 

parties share membership in a medical practice or when one party is a 

member of the other. An example of the former is a relationship in 

which the ordering and billing doctors are members of the same group 

practice (two individuals who own or are otherwise related to a third 

entity). An example of the latter is a relationship in which a group 

practice is a member of a larger health system. An entire service 

episode could occur within a single group practice: different practice 

members might play the roles of orderer, performer, and reader, with 

the practice serving as the biller and payee. 

For purposes of this report, a business relationship exists when two 

parties have a shared business interest, such as shared investments or 

contracts with one another. For example, a radiology group and an 

orthopedic group may operate an imaging center through a joint 

venture. Alternatively, the radiologists within a multispecialty group 

practice might coown the MR equipment used by the practice and lease 

it to the medical practice. Contracts may include lease arrangements, 

whereby a provider leases space, equipment, and/or staff from an 

imaging center. An example is a block lease, whereby the payee leases 

a block of time from an imaging center during which the imaging center 

performs services on behalf of the payee. 

All parties must ensure that their relationships for providing MR 

services comply with Federal prohibitions on self-referral, kickbacks, 

and the markup of tests purchased from other providers.8 These 

prohibitions are in place to protect the Medicare program and its 

beneficiaries from unnecessary and inappropriate use of services. 

Medicare claims readily identify the orderer, biller, and payee for each 

service. The performer of the service and underlying arrangements 

8 Social Security Act § 1128B(b), 42 U.S.C. § 1320a-7b(b); Social Security Act § 1877, 

42 U.S.C. § 1395nn; Social Security Act § 1842(b)(6), 42 U.S.C. § 1395u(b)(6). 

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INTROD U C T I O N 

between providers of MR services, such as leases or coownership, may 

not be evident from the claims. As a result, and because there are many 

ways that providers can work together, it is difficult to identify all of the 

parties and relationships involved in providing each MR service. 

METHODOLOGY 

We based this study on analysis of Medicare claims data and a review of 

a stratified random sample of claims for MR. To review the claims in 

our sample, we conducted a survey of the providers that billed for them 

(i.e., the billers). We augmented claims and survey data with data from 

States, the unique physician identification number (UPIN) file, and the 

Internet. We also visited three MR providers to learn how they provide 

MR services. See Appendix A for a full discussion of our methodology. 

Scope 

This study is national in scope and focuses on the technical component 

of MR services paid under the MPFS in 2005, whether billed globally or 

for the technical component only. We did not evaluate the legality of 

the provider relationships we identified in our review of MR services. 

We did not evaluate the appropriateness or medical necessity of MR 

services. In studying reassignment, we focused on claims for which the 

biller’s UPIN differed from the payee’s UPIN. We did not evaluate 

whether claims were subject to a valid reassignment in accordance with 

all Medicare laws and regulations.9 

Data Collection 

We analyzed Part B data from Medicare’s National Claims History 

(NCH) to create a population file of claims for MR services in 2005. 

Based on our analysis of the NCH, we assigned each service in the 

population to one of three strata: services ordered by doctors whose 

allowed charges for the MR services they ordered placed them at or 

above the 95th percentile among all doctors who ordered MR (high 

users); services ordered by doctors whose charges for all advanced 

imaging—MR, computed tomography, and positron emission 

tomography—placed them at or above the 95th percentile among all 

doctors who ordered these services; and services ordered by doctors who 

were in neither of the other two strata. Our population file contained 

2,624,045 MR claims representing 2,629,061 allowed services and 

9 Social Security Act § 1842(b)(6), 42 U.S.C. § 1395u(b)(6), CMS “Medicare Claims 

Processing Manual,” Pub. No. 100-04, ch.1, § 30.2. 

O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 4 
 

INTROD U C T U C T I O N I O N 
 

$1.8 billion in allowed charges. From this file, we drew a stratified 

simple random sample of 600 claims that were billed through 

548 unique provider numbers. Because it was under investigation by 

OIG, we dropped one provider from our study, leaving 547 billers and 

599 claims in our sample. 

To learn about the MR services in our sample, we surveyed the biller for 

each service. We received completed surveys for 598 of the 599 claims 

in our sample, yielding a response rate of 99.8 percent. We used 

estimates from these 598 claims to project to the population. 

We supplemented our survey data with business registration data from 

States, as well as data about providers from the UPIN file, the 

American College of Radiology Web site, provider Web sites, and Google 

Maps. We used these data sources to identify the performer of each 

service in our sample and to identify business owners, group practices, 

and practice members of the parties involved in each service. 

We then identified relationships among the parties involved in each 

service in our sample. We identified medical practice relationships and 

business relationships. When the orderer or the orderer’s group 

practice had a relationship with a party involved in providing the 

service, we referred to the orderer as a connected doctor and the service 

as a connected service. 

We used data from the claims, including procedure code modifiers, 

provider numbers, and tax identification numbers, to determine 

whether services were billed to Medicare globally or for the technical 

component only. We also used these data to determine whether the 

payment was reassigned from the biller to the payee. 

Analysis 

We analyzed our data to describe MR services overall, those ordered by 

high users of MR, and those ordered by connected doctors. We 

compared services ordered by high users to services ordered by all other 

users, and we compared services ordered by connected doctors to 

services ordered by all other doctors. 

Limitations 

Data from our provider survey were self-reported. With the exception of 

questions related to where the service was performed, we did not 

independently verify these data. 

Because of the proprietary nature of business arrangements that 

providers may use to provide MR services, it is unlikely that our review 

O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 5 
INTRODUCTION 
 

identified all of the business relationships among the parties involved 

with the services in our sample. To the extent that we could not 

identify all such relationships, our estimates of the number of connected 

services might be considered conservative. 

Standards 

We conducted this study in accordance with the “Quality Standards for 

Inspections” issued by the President’s Council on Integrity and 

Efficiency and the Executive Council on Integrity and Efficiency. 

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Δ KEY ANALYTIC CONCEPTS 

In this report, we present data on all MR services and on two subsets of 

MR services: those ordered by high users of MR and those ordered by 

connected doctors (connected services). Below, we introduce key 

concepts related to the findings of this study, including our definitions of 

high users and connected services, and how we used our data sources to 

draw conclusions about MR service delivery. 

Services Ordered by High Users of Magnetic Resonance 

For the purposes of this report, we defined high users of MR as doctors 

whose allowed charges for services that they ordered placed them at or 

above the 95th percentile among all doctors who ordered MR services in 

2005. We identified the subset of services ordered by high users so that 

we could describe how they were provided and compare them to all 

other MR services. Table 2 below displays data about high users and all 

other users. 

Table 2: High Users of Magnetic Resonance and All Other Users of Magnetic 

Resonance in 2005 

High Users All Other Users 

Total number of doctors 

Percentage of all doctors who ordered MR 

Top three specialties 

11,434 

5% 

Orthopedic surgery 

Neurology 

Internal medicine 

217,262 

95% 

Internal medicine 

Family practice 

Orthopedic surgery 

Total MR services ordered 

MR services ordered, percentage of total 

Total charges for MR services ordered 

Charges for MR services ordered, percentage of total 

1,016,918 

39% 

$701,605,244 

40% 

1,607,127 

61% 

$1,072,238,978 

60% 

Average number of MR services ordered per doctor 

Average MR charges per doctor 

89 

$61,361 

7 

$4,935 

Source: OIG analysis of 2005 Part B data, 2008. 

Connected Services 

We defined a connected service as one in which the orderer or the 

orderer’s group was connected—through either a medical practice or 

other business relationship—to one or more of the parties involved in 

providing the technical component of the service. Thus, when a doctor 

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KEY ANALYTIC CONCEPTS 
 

who ordered an MR service was connected to the performer, biller, 

payee, lessor, or coowner, we referred to the doctor as a connected doctor 

and the service as a connected service. We identified the subset of 

connected services so that we could describe how they were provided 

and compare them to all other MR services. 

Data Analysis and Appendixes 

We analyzed two data files to draw our conclusions. One is a file of all 

Part B claims for technical and global MR services paid under the 

MPFS in 2005. We refer to the data in this file as the “population.” The 

other data source is a file with the results of our review of a sample of 

claims we selected from the population. We refer to these data as the 

sample. 

We based our findings on MR services overall and those ordered by high 

users on both projections from the sample and analysis of the 

population. Specifically, our findings on the performer and whether 

payment was reassigned within the biller’s group rely on projections 

from the sample. The rest of our findings on services overall and those 

ordered by high users rely on analysis of the population. 

We based our findings on connected services entirely on projections from 

the sample. 

Appendix B contains supplementary diagrams that display aspects of 

MR service delivery and exceed the level of detail in the body of this 

report. Each set of diagrams contains data about all services, a 

comparison between services ordered by high users and services ordered 

by all other users, and a comparison between services ordered by 

connected doctors and services ordered by all other doctors. When the 

data in a box of a diagram are based on projections from the sample, 

corresponding confidence intervals appear in that diagram’s table of 

confidence intervals. 

Appendix C contains tables related to our findings that rely on 

projections from the sample. When data in a finding are based on 

projections from the sample, corresponding confidence intervals appear 

in Table 1. Table 2 contains the results of statistical tests of sample 

projections. 

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FINDINGS 

 

 

 

Δ FINDINGS 

Certain characteristics were common to a majority 

of magnetic resonance services paid under the 

Medicare Physician Fee Schedule, regardless of 

whether they were ordered by high users 

In 2005, Medicare paid for about 

2.6 million MR services under the 

MPFS. While providers worked 

together to provide services in a 

number of ways, certain 

characteristics related to how they 

were ordered, performed, and billed were common to a majority of 

services. Services largely shared these characteristics whether or not 

they were ordered by high users of MR. 

Two-thirds of services were ordered by one of four specialties 

The doctors who ordered MR were concentrated among a small number 

of specialties. See Table 3 below for the total services ordered by each of 

the top four ordering specialties. 

Table 3: Top Four Ordering Specialties, Magnetic Resonance Services 

Paid Under the Medicare Physician Fee Schedule in 2005 

Specialty Number of Services Percentage of all Services 

Internal medicine 

Orthopedic surgery 

Family practice 

Neurology 

543,727 

504,102 

348,093 

341,737 

21% 

19% 

13% 

13%

 Total Top Four 1,737,659 66% 

Source: OIG analysis of 2005 Part B data, 2008. 

Services ordered by high users of MR were also concentrated among 

these same ordering specialties. However, orthopedic surgeons and 

neurologists together ordered 51 percent of the services ordered by high 

users, compared to 20 percent of all other services. 

Finally, the distribution of payee specialties varied little by the different 

ordering specialties. In other words, no ordering specialty was notably 

associated with any one payee specialty. The distribution of payee 

specialties was largely the same among services overall, those ordered 

by high users, and those ordered by all other users. 

Most services were performed by the entity that was paid by Medicare 

In 2005, the performer and the payee were the same for 85 percent of 

MR services. The other 15 percent of services were performed by 

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F I NDING S 

another party on behalf of the payee. In these cases, the payee might 

have leased imaging capacity from an imaging center or purchased the 

service from another performer. 

Three provider specialties—independent diagnostic testing facility 

(IDTF), multispecialty group, and diagnostic radiology—comprised 

88 percent of performers and payees.10 See Table 1 in Appendix C for 

confidence intervals for findings on performing providers. 

Finally, no statistical differences existed in these percentages among 

MR services overall, those ordered by high users, and those ordered by 

all other users. 

Magnetic resonance claims were typically billed globally through 

radiologists and had payments reassigned 

Services for MR claims followed a consistent billing pattern, regardless 

of whether they were ordered by high users of MR. Claims for 

47 percent of MR services paid under the MPFS in 2005 exhibited all 

three of these characteristics: billed globally, billed through a 

radiologist, and payment reassigned. 

Seventy-eight percent of services were billed globally. Global billing 

consolidates the professional and technical components into a single claim 

for payment to a single provider. Globally billed services can be furnished 

in several ways. Examples include a single provider, such as an imaging 

center, a radiology group practice, or another group practice, furnishing 

both components; an agreement between a radiology practice, which 

provides the professional component, and an imaging center, which 

provides the technical component; and a radiologist working under 

contract to furnish the professional component of services performed by 

imaging centers and group practices. 

Fifty-four percent of all services were billed through a radiologist’s 

provider number. When a radiologist was the biller for the service, the 

radiologist could have provided either or both the technical and 

professional components of the test. 

For purposes of this report, we classified a service as having had payment 

reassigned when the biller’s UPIN differed from the payee’s UPIN. We 

determined that payment was reassigned for 68 percent of services. 

Eighty-six percent of reassignments were from a doctor to his or her group 

10 In Medicare claims data, IDTF and multispecialty group are considered nonphysician 

provider specialties. CMS, “Medicare Claims Processing Manual,” Pub. No. 100-4, ch. 26. 

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F I NDING S 

practice. For the remaining 14 percent of reassignments, we were unable 

to identify the connection between the payee and the biller. Payment for 

global bills was reassigned 71 percent of the time, while payment for 

technical component-only bills was reassigned 53 percent of the time. See 

Table 1 in Appendix C for confidence intervals for percentages of services 

with payments reassigned from a doctor to his or her group practice and 

those with payments reassigned to a provider with no identified 

connection. 

Finally, billing for services largely reflected these characteristics 

whether or not they were ordered by high users of MR. Seventy-eight 

percent of services ordered by high users were billed globally, 52 percent 

were billed through a radiologist’s provider number, and 68 percent had 

payment reassigned. These percentages are nearly identical to those for 

services ordered by all other users. In addition, no statistical 

differences existed in the percentage of payments reassigned within the 

biller’s group among MR services overall, those ordered by high users, 

and those ordered by all other users. 

In our review, we found that one-quarter Connected services were provided differently 

of MR services paid under the MPFS in than services that were not connected 

2005 were connected services. In these 

services, the ordering doctor or the ordering doctor’s group had a 

medical practice or other business connection to one or more of the 

parties involved in providing the service. All differences between 

connected and all other services (those that were not connected) that 

appear below were statistically significant at the 95-percent confidence 

level. See Tables 1 and 2 in Appendix C for corresponding confidence 

intervals and statistical tests. 

Connected services were associated with high use 

High users of MR ordered 55 percent of connected services, compared to 

33 percent of services that were not connected. 

Connected services were more likely to have been ordered by orthopedic 

surgeons 

Orthopedic surgeons ordered 28 percent of connected services, compared 

to 15 percent of all other services. Among the four most prevalent 

ordering specialties—internal medicine, orthopedic surgery, family 

practice, and neurology—this is the only difference in the percentages of 

services each ordered that was statistically significant. 

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F I NDING S 

Connected services were more likely to have been performed by 

multispecialty groups 

Multispecialty groups performed and were paid for half of connected 

services, compared to only one-quarter of services that were not 

connected. The IDTF and diagnostic radiology specialties played a 

smaller role in connected services than in all other services. Specialties 

other than multispecialty group, IDTF, and diagnostic radiology played 

a significantly larger role in connected services than in all other 

services. See Tables 4 and 5 below for a comparison of top performer 

and payee specialties for connected services and those that were not 

connected. 

Table 4: Top Specialties of Performers, Connected Services, and 

All Other Services 

Performer Specialty 

Percentage of 

Connected Services 

Percentage of All 

Other Services 

Multispecialty clinic/group 

IDTF 

Diagnostic radiology 

All other specialties 

50% 

13% 

7% 

30% 

26% 

39% 

29% 

6%

 Total 100% 100% 

Source: OIG review of 2005 MR services, 2008. 

Table 5: Top Specialties of Payees, Connected Services, and All 

Other Services 

Payee Specialty 

Percentage of 

Connected Services 

Percentage of All 

Other Services 

Multispecialty clinic/group 

IDTF 

Diagnostic radiology 

All other specialties 

51% 

11% 

7% 

31% 

26% 

38% 

31% 

5%

 Total 100% 100% 

Source: OIG review of 2005 MR services, 2008. 

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FINDINGS 

Connected services were more likely than all other services to have been 

billed as technical component only, to have had payment reassigned, and to 

have been billed through a provider other than a radiologist 

See Chart 1 below for a comparison of the billing characteristics of 

connected services and all other services. 

Chart 1: Billing Characteristics of Connected and 

All Other Services
 

100% 

75% 

87% 

63% 

14% 

64% 

38% 

33% 

Connected 

services 

50% 

All other 

services 

25% 

0%
 

Technical component- Payment reassigned Billed through a provider
 

only bill other than a radiologist
 

Source: OIG review of 2005 MR services, 2008. 

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Δ CONCLUSION 

The Medicare program has seen rapid growth in MR and other types of 

advanced imaging performed in doctors’ offices, imaging centers, and 

other settings covered by the MPFS. As more services are performed in 

these settings, doctors are increasingly in a position to order services 

from parties with which they have a medical practice or other business 

relationship. In these circumstances, doctors may have conflicts of 

interest, financial or otherwise. 

In this review, we sought to learn about how providers delivered MR 

covered under the MPFS and whether certain relationships among 

providers were associated with high use of services. In particular, we 

were interested in connected services, which are services ordered by 

doctors who were connected to the parties that provided them. 

We found a relationship between connected services and services 

ordered by high users of MR, but we also found that the two subsets of 

services differed in several ways. We found that services ordered by 

high users of MR were largely similar to all other services in how they 

were furnished and billed to Medicare. However, this was not the case 

for connected services, which differed significantly from services that 

were not connected. 

The findings in this report highlight the complex nature of how 

providers deliver MR paid under the MPFS. The large number of ways 

that various parties can perform and bill for services reduces the 

transparency of these transactions. Although the analysis in this report 

was limited to MR, it is possible that such complexity extends to other 

types of high-cost imaging paid under the MPFS. The complexity and 

limited transparency with which these services are provided warrants 

continued attention to ensure that services are reasonable, necessary, 

and compliant with Medicare statutes and regulations. 

AGENCY COMMENTS 

CMS agreed with our findings and our conclusion that the complexity of 

MR services warrants continuted attention. It outlined regulatory steps 

it has taken to curb overutilization of diagnostic testing services. These 

include expanding the antimarkup provision to the professional 

component of services and seeking public comment on the in-office 

ancillary exception to the physician self-referral law. CMS also stated 

its commitment to examining the relationship between the utilization of 

advanced imaging services and the entities that order and bill for them. 

The complete text of CMS’s comments appears in Appendix D. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 14 
 

Δ APPENDIX~A 

Methodology 

We based this study on analysis of Medicare claims data and a review of 

a stratified random sample of claims for magnetic resonance (MR). To 

review the claims in our sample, we conducted a survey of the providers 

that billed for them. We augmented our survey data with business 

registration data from States and data about providers from the unique 

physician identification number (UPIN) file, the American College of 

Radiology Web site, provider Web sites, and Google Maps. We also 

visited three MR providers to learn how they provide MR services. 

Scope 

This study is national in scope and focuses on the technical component 

of MR services paid under the Medicare Physician Fee Schedule (MPFS) 

in 2005. We focused on the technical component because it is the most 

costly component of MR services. We focused on MR because it has a 

wide range of clinical applications across ambulatory settings. 

We used 100-percent Part B carrier claims data from Medicare’s 

National Claims History (NCH) and data from a stratified simple 

random sample to describe MR services. 

We did not attempt to make any judgments about the legality of the 

provider relationships we identified in our review. 

Creation of Population File 

The data source for our sample was Medicare’s 2005 NCH, which 

contains all claims activity for Medicare fee-for-service beneficiaries. 

From this source, we created a population file of 2,624,045 Part B 

claims for MR services from which we drew our sample. We also used 

this population file in our descriptive analysis of how MR services were 

furnished and billed. Below are the steps we took to create this file and 

draw our sample. 

Create a file of claims for global and technical component services. We 

extracted Part B carrier claims from the 2005 NCH to create a file of 

technical component and global claims for MR, computed tomography 

(CT), and positron emission tomography (PET). This file contained 

6,009,091 claims reflecting $3.3 billion in allowed charges. 

We then excluded 172,585 records with invalid data for the UPIN of the 

ordering doctor or allowed charges under $100. We did so because we 

needed valid UPIN data to profile ordering doctors and because claims 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 15 
 

 

A P P E N D I X ~ A 

with allowed charges under $100 were unlikely to be for the technical 

component of services. These represent 2.9 percent of the records in our 

original file and 2.9 percent of allowed charges. 

The resulting file contained 5,836,506 claim records. Each record 

contained the Healthcare Common Procedure Coding System (HCPCS) 

code and modifiers, UPIN number and specialty of the biller, UPIN 

number of the orderer, tax identification number of the payee, and 

beneficiary identifier. 

Create profiles of ordering doctors. We summarized our claims file by 

orderer’s UPIN to create a profile record for each doctor who ordered 

one or more services. The resulting file had 284,105 records. Each 

record contained allowed charges for MR, CT, and PET ordered by the 

doctor in 2005—for each modality and for all three combined. Records 

also included percentile rankings based on those charges. Of the 

orderers in the file, 228,696 ordered MR. Based on analysis of the 

distributions of allowed charges in the file, we categorized each orderer 

of MR into one of three strata: doctors whose allowed charges for the 

MR services they ordered placed them at or above the 95th percentile 

among all doctors who ordered MR (high group); doctors whose 

collective charges for MR, CT, and PET services placed them at or above 

the 95th percentile among all doctors who ordered these services 

(collective high group); and doctors who were in neither the high nor the 

collective high strata (regular group). 

Append profiles to MR claims and assign claims to strata. Our population file 

contained 2,624,045 MR claims representing 2,629,061 allowed services 

and $1.8 billion in allowed charges. Next, we merged each orderer’s 

profile with the claims for MR services that he or she ordered. This 

enabled us to assign each claim to a stratum based on whether its 

orderer was in the high, collective high, or regular group of MR users. 

Sample Selection 

From our stratified population file, we drew a stratified simple random 

sample of claims for services ordered by high, collective high, and 

regular users. The population and sample size for each stratum are 

shown in Table 1 on the following page. 

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APPENDIX~A 

Table 1: Population of Magnetic Resonance Claims and Sample Strata 

Stratum Ordering Doctor's 

Use of MR 2005 Population Allowed Charges Sample Size 

1 

2 

3 

High 

Collective High 

Regular 

1,016,918 

19,695 

1,587,432 

$701,605,244 

$15,526,233 

$1,056,712,744 

200 

100 

300 

Total 2,624,045 $1,773,844,221 600 

Source: Office of Inspector General (OIG) analysis of 2005 Part B data, 2006. 

The 600 claims in our sample were billed under a total of 548 unique 

provider numbers. We used the UPIN file to locate the names and 

addresses of these billers and vetted them with our Office of 

Investigations. As a result of vetting, we dropped one provider from our 

study, leaving 547 billers and 599 claims in our sample. 

Mail Survey 

To learn about how MR services in our sample were provided, we 

surveyed the biller for each service. The survey contained 14 questions 

related to the biller’s relationship with the orderer of the service, the 

name and location of the performer, equipment ownership and leasing, 

and whether the provider had a business or medical practice 

relationship with any of the parties involved in providing the service. 

We tested the survey with four providers and vetted it within OIG. 

To conduct the survey, we used express delivery to send each biller a 

package with a cover letter, a survey, a preaddressed prepaid return 

envelope, and an instructions page with information identifying the 

specific service about which we were asking. We instructed the biller to 

answer the survey only with respect to the technical component of the 

specific service identified. If a biller had more than one claim in our 

sample, we sent an instruction sheet and survey for each claim. 

We received completed surveys from 546 of the 547 billers in our 

sample. We could not locate one biller that had retired from medical 

practice. The surveys we received covered 598 of the 599 claims in our 

sample, yielding a response rate of 99.8 percent. 

Supplemental Data 

To learn more about how MR services in our sample were provided, we 

supplemented our survey data with business registration data from 

States, as well as data about providers from the UPIN file, the 

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APPENDIX~A 

American College of Radiology Web site, provider Web sites, and Google 

Maps. 

We used business registration data from States to identify owners of 

any business that played a role in providing a service. Such businesses 

included equipment leasing companies, imaging centers, and medical 

groups incorporated as professional corporations. We used the UPIN 

file to identify group practices and group practice members of all 

primary parties involved with the services. We also cross-referenced the 

payee tax identification number from each sampled claim with the 

UPIN file to identify the payee for each service in our sample. We used 

provider Web sites to identify practice members, locations, and 

affiliations with other providers. We used the American College of 

Radiology’s Web site and Google Maps to aid in verifying performers’ 

locations. Any time we identified an individual, group practice, or other 

provider associated with a claim, we searched the UPIN file by provider 

name and location to identify and record that provider’s UPIN. 

Identification of Relationships and Connected Doctors 

We used both a computer program and a manual review to identify 

medical practice relationships and business relationships among the 

primary parties involved with each service in our sample. We defined 

medical practice relationships as a doctor who was member of a group 

practice or on staff at a hospital. Business relationships included 

shared participation as investors in a joint venture, one party having an 

ownership or managerial interest in the other, and contracts. 

When we determined that the orderer or the orderer’s group practice 

had a relationship with one or more of the parties involved in providing 

the service, we referred to the orderer as a connected doctor and the 

service as a connected service. 

Description of Billing Attributes 

We classified all claims in our population as bills for either global 

payment or for the technical component only and as either having had 

payment reassigned or not having had payment reassigned. To classify 

a service as billed globally or for the technical component only, we used 

the two HCPCS modifiers that were on the claim. To classify a service 

as having had payment reassigned, we used the UPIN numbers of the 

biller and the payee. When the biller’s UPIN differed from the payee’s 

UPIN, we classified the service as having had its payment reassigned. 

We did not determine whether other types of reassignments may have 

occurred. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 18 
APPENDIX~A 

When we classified services in our sample as having had payment 

reassigned, we used the UPIN file and our supplemental data to 

determine whether payment was reassigned within the biller’s group. 

When the UPIN file or our supplemental data showed that the biller 

was a member of the payee, we classified the reassignment as within 

the biller’s group. 

Analysis 

Findings and conclusions are based on analyses of data from the 

population file and from our sample. 

We analyzed these data to describe MR services overall, the subset of 

those ordered by high users of MR, and the subset of those ordered by 

connected doctors. We compared services ordered by high users to 

services ordered by all other users and compared services ordered by 

connected doctors to services ordered by all other doctors. 

We based our findings on MR services overall and those ordered by high 

users on analysis of both the sample and the population. Specifically, 

our findings on the performer and whether payment was reassigned 

within the biller’s group rely on analysis of the sample. The rest of our 

findings on services overall and those ordered by high users rely on 

analysis of the population. 

We based our findings on connected services entirely on analysis of the 

sample. 

Limitations 

Data from our provider survey were self-reported. With the exception of 

questions related to where the service was performed, we did not 

independently verify these data. 

Because of the proprietary nature of business arrangements that 

providers may use to provide MR services, it is unlikely that our review 

identified all of the business relationships among the parties involved 

with the services in our sample. To the extent that we could not 

identify all such relationships, our estimates might be considered 

conservative. 

We considered each claim in our population file to represent one MR 

service. However, our population file contained 3,219 claims for more 

than one service. We found that claims with more than one service had 

average allowed charges per service of $566 and that those with more 

than two services had allowed charges per service of $248. This 

compares to $675 for claims with one service only. Instead of reviewing 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 19 
APPENDIX~A 

each of the claims with more than one service to judge whether their 

service counts were valid, we decided to count them as claims for one 

service only. The additional services that we did not count on these 

claims totaled 5,016 services, or 0.2 percent of our sample population. 

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Δ APPENDIX~B 

Magnetic Resonance Service Delivery Diagrams 

DIAGRAM 1 : SERVICE DELIVERY ...................... 22 
 

1a: All services ........................................ 22 
 

1b: Services ordered by high users ........................ 23 
 

1c: Services ordered by all other users ..................... 24 
 

1d: Services ordered by connected doctors .................. 25 
 

1e: Services ordered by all other doctors.................... 26 
 

DIAGRAM 2 : REASSIGNMENT OF PAYMENT ........... 27 
 

2a: All services ........................................ 27 
 

2b: Services ordered by high users ........................ 28 
 

2c: Services ordered by all other users ..................... 29 
 

2d: Services ordered by connected doctors .................. 30 
 

2e: Services ordered by all other doctors.................... 31 
 

DIAGRAM 3 : BILLING METHOD ......................... 32 
 

3a: All services ........................................ 32 
 

3b: Services ordered by high users ........................ 33 
 

3c: Services ordered by all other users ..................... 34 
 

3d: Services ordered by connected doctors .................. 35 
 

3e: Services ordered by all other doctors.................... 36 
 

DIAGRAM 4 : PROVIDER RELATIONSHIPS .............. 37 
 

4a: All services ........................................ 37 
 

4b: Services ordered by high users ........................ 38 
 

4c: Services ordered by all other users ..................... 39 
 

4d: Services ordered by connected doctors .................. 40 
 

4e: Services ordered by all other doctors.................... 41 
 

CONFIDENCE INTERVAL TABLES ....................... 42 
 

 OEI-01-06-00261 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 21 
APPENDIX~B 

Diagram 1a: Service Delivery, All Services 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: Office of Inspector General (OIG) analysis of 2005 Part B data and OIG review of 2005 

magnetic resonance (MR) services, 2008. 

See Table 1a on p. 42 for confidence intervals. 

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APPENDIX~B 

Diagram 1b: Service Delivery, Services Ordered by High Users 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG analysis of 2005 Part B data and OIG review of 2005 MR services, 2008. 

See Table 1b on p. 43 for confidence intervals. 

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APPENDIX~B 

Diagram 1c: Service Delivery, Services Ordered by All Other Users 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG analysis of 2005 Part B data and OIG review of 2005 MR services, 2008. 

See Table 1c on p. 44 for confidence intervals. 

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APPENDIX~B 

Diagram 1d: Service Delivery, Services Ordered by Connected Doctors 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG review of 2005 MR services, 2008. 

See Table 1d on p. 45 for confidence intervals. 

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APPENDIX~B 

Diagram 1e: Service Delivery, Services Ordered by All Other Doctors 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG review of 2005 MR services, 2008. 

See Table 1e on p. 46 for confidence intervals. 

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APPENDIX~B 

Diagram 2a: Reassignment of Payment, All Services 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG analysis of 2005 Part B data and OIG review of 2005 MR services, 2008. 

See Table 2a on p. 47 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 27 
APPENDIX~B 

Diagram 2b: Reassignment of Payment, Services Ordered by High Users 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG analysis of 2005 Part B data and OIG review of 2005 MR services, 2008. 

See Table 2b on p. 47 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 28 
APPENDIX~B 

Diagram 2c: Reassignment of Payment, Services Ordered by All Other Users 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG analysis of 2005 Part B data and OIG review of 2005 MR services, 2008. 

See Table 2c on p. 47 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 29 
APPENDIX~B 

Diagram 2d: Reassignment of Payment, Services Ordered by Connected Doctors 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG analysis of 2005 Part B data and OIG review of 2005 MR services, 2008. 

See Table 2d on p. 47 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 30 
APPENDIX~B 

Diagram 2e: Reassignment of Payment, Services Ordered by All Other Doctors 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG analysis of 2005 Part B data and OIG review of 2005 MR services, 2008. 

See Table 2e on p. 47 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 31 
APPENDIX~B 

Diagram 3a: Billing Method, All Services 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG analysis of 2005 Part B data and OIG review of 2005 MR services, 2008. 

See Table 3a on p. 48 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 32 
APPENDIX~B 

Diagram 3b: Billing Method, Services Ordered by High Users 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG analysis of 2005 Part B data and OIG review of 2005 MR services, 2008. 

See Table 3b on p. 48 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 33 
APPENDIX~B 

Diagram 3c: Billing Method, Services Ordered by All Other Users 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG analysis of 2005 Part B data and OIG review of 2005 MR services, 2008. 

See Table 3c on p. 48 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 34 
APPENDIX~B 

Diagram 3d: Billing Method, Services Ordered by Connected Doctors 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG review of 2005 MR services, 2008. 

See Table 3d on p. 49 for confidence intervals. 

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APPENDIX~B 

Diagram 3e: Billing Method, Services Ordered by All Other Doctors 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG review of 2005 MR services, 2008. 

See Table 3e on p. 49 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 36 
APPENDIX~B 

Diagram 4a: Provider Relationships, All Services 

* 

“CX” = Connection: Parties are the same or one is a member of the other. 

Percentages in one column may not add to those in the preceding column because of rounding. 

* Projections in the right-most column are based on 589 sample units and those in the column that 

precedes it are based on 590. This causes some percentages in the right-most column to vary 

from the values in the preceding column. 

Source: OIG review of 2005 MR services, 2008. 

See Table 4a on p. 50 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 37 
APPENDIX~B 

Diagram 4b: Provider Relationships, Services Ordered by High Users 

* 

“CX” = Connection: Parties are the same or one is a member of the other. 

Percentages in one column may not add to those in the preceding column because of rounding. 

* Projections in the right-most column are based on 195 sample units and those in the column 

that precedes it are based on 196. This causes some percentages in the right-most column to 

vary from the values in the preceding column. 

Source: OIG review of 2005 MR services, 2008. 

See Table 4b on p. 51 for confidence intervals. 

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APPENDIX~B 

Diagram 4c: Provider Relationships, Services Ordered by All Other Users 

“CX” = Connection: Parties are the same or one is a member of the other. 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG review of 2005 MR services, 2008. 

See Table 4c on p. 52 for confidence intervals. 

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APPENDIX~B 

Diagram 4d: Provider Relationships, Services Ordered by Connected Doctors 

“CX” = Connection: Parties are the same or one is a member of the other. 

Percentages in one column may not add to those in the preceding column because of rounding. 

Source: OIG review of 2005 MR services, 2008. 

See Table 4d on p. 53 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 40 
APPENDIX~B 

Diagram 4e: Provider Relationships, Services Ordered by All Other Doctors 

* 

“CX” = Connection: Parties are the same or one is a member of the other. 

Percentages in one column may not add to those in the preceding column because of rounding. 

* Projections in the right-most column are based on 449 sample units and those in the column 

that precedes it are based on 450. This causes some percentages in the right-most column to 

vary from the values in the preceding column. 

Source: OIG review of 2005 MR services, 2008. 

See Table 4e on p. 54 for confidence intervals. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 41 
 

 

 

 

 

 

 

 

 

 

A P P E N D I X ~ B 

Table 1a: Confidence Intervals for Diagram 1a: Service Delivery, All Services 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Payee connected to Performer 

Reassigned 

Within group 

Outside group 

Biller UPIN same as Payee UPIN 

Payee not connected to Performer 

Reassigned 

Within group 

Outside group 

Biller UPIN same as Payee UPIN 

85.3% 

58.5% 

50.4% 

8.2% 

26.7% 

14.7% 

11.5% 

9.5% 

2.0% 

3.2% 

590 

589 

589 

589 

589 

590 

589 

589 

589 

589 

82.1%–88.4% 

54.2%–62.9%

46.0%–54.8%

5.7%–10.6% 

22.8%–30.6% 

11.6%–17.9% 

8.7%–14.3%

6.9%–12.1%

1.1%–3.7%* 

1.7%–4.8% 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method 

when a small number of sample elements possess the characteristic of interest. 

O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 42 
 

 

 

 

 

 

 

 

APPENDIX~B 

Table 1b: Confidence Intervals for Diagram 1b: Service Delivery, Services Ordered by 

High Users 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Payee connected to Performer 

Reassigned 

 Within group 

 Outside group 

Biller UPIN same as Payee UPIN 

Payee not connected to Performer 

Reassigned 

 Within group 

 Outside group 

Biller UPIN same as Payee UPIN 

82.7% 

60.0% 

53.3% 

6.7% 

22.6% 

17.3% 

13.8% 

10.3% 

3.6% 

3.6% 

196 

195 

195 

195 

195 

196 

195 

195 

195 

195 

77.3%–88.0% 

53.1%–66.9%

46.3%–60.4%

3.1%–10.2% 

16.7%–28.5% 

12.0%–22.7% 

9.0%–18.7%

6.0%–14.5%

1.0%–6.2% 

1.0%–6.2% 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 43 
 

 

 

 

 

 

 

 

APPENDIX~B 

Table 1c: Confidence Intervals for Diagram 1c: Service Delivery, Services Ordered by All 

Other Users 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Payee connected to Performer 

Reassigned 

 Within group 

 Outside group 

Biller UPIN same as Payee UPIN 

Payee not connected to Performer 

Reassigned 

 Within group 

 Outside group 

Biller UPIN same as Payee UPIN 

86.9% 

57.6% 

48.5% 

9.1% 

29.3% 

13.1% 

10.1% 

9.1% 

1.0% 

3.0% 

394 

394 

394 

394 

394 

394 

394 

394 

394 

394 

83.1%–90.7% 

52.0%–63.2%

42.9%–54.2%

5.8%–12.3% 

24.2%–34.4% 

9.3%–16.9% 

6.7%–13.5%

5.8%–12.3%

0.3%–3.1%* 

1.1%–5.0% 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method 

when a small number of sample elements possess the characteristic of interest. 

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APPENDIX~B 

Table 1d: Confidence Intervals for Diagram 1d: Service Delivery, Services Ordered by 

Connected Doctors 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Payee connected to Performer 

Reassigned 

 Within group 

 Outside group 

Biller UPIN same as Payee UPIN 

Payee not connected to Performer 

Reassigned 

 Within group 

 Outside group 

Biller UPIN same as Payee UPIN 

79.2% 

69.6% 

60.7% 

9.0% 

9.6% 

20.8% 

17.6% 

16.0% 

1.6% 

3.2% 

140 

140 

140 

140 

140 

140 

140 

140 

140 

140 

72.1%–86.3% 

61.6%–77.7%

52.1%–69.2%

3.9%–14.0% 

4.4%–14.7% 

13.7%–27.9% 

10.9%–24.3%

9.6%–22.5%

0.4%–6.1%* 

1.2%–8.2%* 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method 

when a small number of sample elements possess the characteristic of interest. 

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A P P E N D I X ~ B 

Table 1e: Confidence Intervals for Diagram 1e: Service Delivery, Services Ordered by All 

Other Doctors 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Payee connected to Performer 

Reassigned 

Within group 

Outside group 

Biller UPIN same as Payee UPIN 

Payee not connected to Performer 

Reassigned 

Within group 

Outside group 

Biller UPIN same as Payee UPIN 

87.3% 

54.8% 

46.9% 

7.9% 

32.4% 

12.7% 

9.5% 

7.4% 

2.1% 

3.3% 

450 

449 

449 

449 

449 

450 

449 

449 

449 

449 

83.9%–90.7% 

49.8%–59.9%

41.9%–52.0%

5.1%–10.6% 

27.7%–37.2% 

9.3%–16.1% 

6.5%–12.5%

4.7%–10.0%

1.1%–4.2%* 

1.4%–5.1% 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method 

when a small number of sample elements possess the characteristic of interest. 

O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 46 
 

 

 

 

 

 

 

 

 

APPENDIX~B 

Table 2a: Confidence Intervals for Diagram 2a: Reassignment of Payment, All Services 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Reassigned within group 

Reassigned outside group 

59.2% 

9.9% 

417 

417 

56.7%–61.7% 

7.4%–12.4% 

Table 2b: Confidence Intervals for Diagram 2b: Reassignment of Payment, Services Ordered by 

High Users 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Reassigned within group 

Reassigned outside group 

60.5% 

9.5% 

147 

147 

56.6%–64.4% 

5.6%–13.4% 

Table 2c: Confidence Intervals for Diagram 2c: Reassignment of Payment, Services Ordered by All 

Other Users 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Reassigned within group 

Reassigned outside group 

58.4% 

10.2% 

270 

270 

55.0%–61.7% 

6.8%–13.5% 

Table 2d: Confidence Intervals for Diagram 2d: Reassignment of Payment, Services Ordered by 

Connected Doctors 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Reassigned 

 Reassigned within group 

 Reassigned outside group 

Biller UPIN paid 

87.4% 

76.9% 

10.5% 

12.6% 

141 

141 

141 

141 

81.6%–93.2%

69.5%–84.3%

5.1%–15.8% 

6.8%–18.4% 

Table 2e: Confidence Intervals for Diagram 2e: Reassignment of Payment, Services Ordered by All 

Other Doctors 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Reassigned 

 Reassigned within group 

 Reassigned outside group 

Biller UPIN paid 

64.3% 

54.4% 

9.9% 

35.7% 

456 

456 

456 

456 

59.4%–69.1%

49.3%–59.4%

6.9%–12.9% 

30.9%–40.6% 

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APPENDIX~B 

Table 3a: Confidence Intervals for Diagram 3a: Billing Method, All Services 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Global bill, reassigned within group 

Global bill, reassigned outside group 

TC bill, reassigned within group 

TC bill, reassigned outside group 

49.1% 

8.2% 

10.1% 

1.7% 

355 

355 

62 

62 

46.8%–51.4% 

5.9%–10.5% 

9.0%–11.2% 

0.9%–3.1%* 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small 

number of sample elements possess the characteristic of interest. 

Table 3b: Confidence Intervals for Diagram 3b: Billing Method, Services Ordered by High Users 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Global bill, reassigned within group 

Global bill, reassigned outside group 

TC bill, reassigned within group 

TC bill, reassigned outside group 

48.6% 

8.4% 

12.0% 

1.0% 

122 

122 

25 

25 

45.0%–52.2% 

4.8%–12.0% 

10.6%–13.0% 

0.3%–3.5%* 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small 

number of sample elements possess the characteristic of interest. 

Table 3c: Confidence Intervals for Diagram 3c: Billing Method, Services Ordered by All Other Users 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Global bill, reassigned within group 

Global bill, reassigned outside group 

TC bill, reassigned within group 

TC bill, reassigned outside group 

49.4% 

8.0% 

8.9% 

2.2% 

233 

233 

37 

37 

46.5%–52.4% 

5.1%–11.0% 

7.3%–10.5% 

1.0%–4.2%* 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small 

number of sample elements possess the characteristic of interest. 

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APPENDIX~B 

Table 3d: Confidence Intervals for Diagram 3d: Billing Method, Services Ordered by Connected 

Doctors 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Global bill 

 Reassigned 

 Within group 

 Outside group 

 Biller UPIN same as Payee UPIN 

TC bill 

 Reassigned 

 Within group 

 Outside group 

 Biller UPIN same as Payee UPIN 

66.5% 

60.3% 

52.2% 

8.1% 

6.3% 

33.5% 

27.1% 

24.7% 

2.4% 

6.4% 

141 

141 

141 

141 

141 

141 

141 

141 

141 

141 

58.3%–74.8%

51.7%–68.8%

43.4%–60.9%

3.3%–12.8%

2.1%–10.5% 

25.2%–41.7%

19.3%–34.9%

17.1%–32.3%

0.8%–7.2%*

2.1%–10.6% 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small 

number of sample elements possess the characteristic of interest. 

Table 3e: Confidence Intervals for Diagram 3e: Billing Method, Services Ordered by All Other 

Doctors 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Global bill 

 Reassigned 

 Within group 

 Outside group 

 Biller UPIN same as Payee UPIN 

TC bill 

 Reassigned 

 Within group 

 Outside group 

 Biller UPIN same as Payee UPIN 

86.0% 

58.6% 

50.0% 

8.6% 

27.4% 

14.0% 

5.7% 

4.3% 

1.3% 

8.4% 

456 

456 

456 

456 

456 

456 

456 

456 

456 

456 

82.5%–89.5%

53.6%–63.6%

45.0%–55.1%

5.7%–11.4%

22.9%–31.9% 

10.5%–17.5%

3.3%–8.0%

2.3%–6.4%

0.6%–3.2%*

5.6%–11.2% 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small 

number of sample elements possess the characteristic of interest. 

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APPENDIX~B 

Table 4a: Confidence Intervals for Diagram 4a: Provider Relationships, All Services 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Referring physician connected to Performer 17.9% 590 14.6%–21.3%

 Performer connected to Biller 15.1% 590 12.0%–18.2%

 Biller connected to Payee 15.1% 589 12.0%–18.3%

 Biller not connected to Payee 0.0% 589 n/a

 Performer not connected to Biller 2.8% 590 1.4%–4.3%

 Biller connected to Payee 1.2% 589 0.6%–2.7%*

 Biller not connected to Payee 1.6% 589 0.8%–3.2%* 

Referring physician not connected to Performer 82.1% 590 78.7%–85.4%

 Performer connected to Biller 65.4% 590 61.3%–69.6%

 Biller connected to Payee 65.0% 589 60.8%–69.2%

 Biller not connected to Payee 0.6% 589 0.2%–1.8%*

 Performer not connected to Biller 16.6% 590 13.3%–19.9%

 Biller connected to Payee 8.5% 589 6.1%–11.0%

 Biller not connected to Payee 7.9% 589 5.6%–10.3% 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small 

number of sample elements possess the characteristic of interest. 

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APPENDIX~B 

Table 4b: Confidence Intervals for Diagram 4b: Provider Relationships, Services Ordered by High 

Users 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Referring physician connected to Performer 22.4% 196 16.6%–28.3%

 Performer connected to Biller 19.4% 196 13.8%–24.9%

 Biller connected to Payee 19.5% 195 13.9%–25.1%

 Biller not connected to Payee 0.0% 195 0.0%–1.9%

 Performer not connected to Biller 3.1% 196 1.1%–6.5%*

 Biller connected to Payee 1.0% 195 0.1%–3.7%*

 Biller not connected to Payee 2.1% 195 0.6%–5.2%* 

Referring physician not connected to Performer 77.6% 196 71.7%–83.4%

 Performer connected to Biller 61.2% 196 54.4%–68.1%

 Biller connected to Payee 60.0% 195 53.1%–66.9%

 Biller not connected to Payee 1.5% 195 0.3%–4.4%*

 Performer not connected to Biller 16.3% 196 11.1%–21.5%

 Biller connected to Payee 9.2% 195 5.1%–13.3%

 Biller not connected to Payee 6.7% 195 3.1%–10.2% 

* Confidence interval calculated with an exact method based on the binomial distribution because of poor coverage properties of the standard 

approximation method when a small number of sample elements possess the characteristic of interest. 

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APPENDIX~B 

Table 4c: Confidence Intervals for Diagram 4c: Provider Relationships, Services Ordered by All 

Other Users 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Referring physician connected to Performer 15.1% 394 11.1%–19.2%

 Performer connected to Biller 12.4% 394 8.7%–16.2%

 Biller connected to Payee 12.4% 394 8.7%–16.2%

 Biller not connected to Payee 0.0% 394 n/a

 Performer not connected to Biller 2.7% 394 1.4%–5.3%*

 Biller connected to Payee 1.3% 394 0.5%–3.5%*

 Biller not connected to Payee 1.3% 394 0.5%–3.5%* 

Referring physician not connected to Performer 84.9% 394 80.8%–88.9%

 Performer connected to Biller 68.1% 394 62.8%–73.3%

 Biller connected to Payee 68.1% 394 62.8%–73.3%

 Biller not connected to Payee 0.01% 394 0.002%–0.1%*

 Performer not connected to Biller 16.8% 394 12.6%–21.0%

 Biller connected to Payee 8.1% 394 5.0%–11.1%

 Biller not connected to Payee 8.7% 394 5.6%–11.9% 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small 

number of sample elements possess the characteristic of interest. 

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APPENDIX~B 

Table 4d: Confidence Intervals for Diagram 4d: Provider Relationships, Services Ordered by 

Connected Doctors 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Referring physician connected to Performer 72.0% 140 64.1%–79.8%

 Performer connected to Biller 60.6% 140 52.0%–69.2%

 Biller connected to Payee 60.6% 140 52.0%–69.2%

 Biller not connected to Payee 0.0% 140 n/a

 Performer not connected to Biller 11.4% 140 5.8%–16.9%

 Biller connected to Payee 4.9% 140 1.1%–8.7%

 Biller not connected to Payee 6.5% 140 2.1%–10.8% 

Referring physician not connected to Performer 28.0% 140 20.2%–35.9%

 Performer connected to Biller 15.2% 140 8.9%–21.4%

 Biller connected to Payee 14.4% 140 8.3%–20.5%

 Biller not connected to Payee 0.8% 140 0.1%–5.4%*

 Performer not connected to Biller 12.9% 140 7.0%–18.7%

 Biller connected to Payee 9.6% 140 4.4%–14.7%

 Biller not connected to Payee 3.3% 140 1.3%–8.4%* 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small 

number of sample elements possess the characteristic of interest. 

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A P P E N D I X ~ B 

Table 4e: Confidence Intervals for Diagram 4e: Provider Relationships, Services Ordered by All 

Other Doctors 

Service Characteristic Point Estimate Sample Size 

95-Percent Confidence 

Interval 

Referring physician not connected to Performer

 Performer connected to Biller 

Biller connected to Payee 

Biller not connected to Payee 

Performer not connected to Biller 

Biller connected to Payee 

Biller not connected to Payee 

82.1% 

81.8% 

0.5% 

17.9% 

8.2% 

9.5% 

450 

449 

449 

450 

449 

449 

78.3%–86.0%

77.9%–85.7%

0.1%–2.1%*

14.0%–21.8%

5.4%–10.9%

6.5%–12.5% 

* Confidence interval calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small 

number of sample elements possess the characteristic of interest. 

O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 54 
APPENDIX~C 

 

 

 

 

 

 

 

 

Δ APPENDIX~C 

Statistical Tables 

Table 1: Confidence Intervals 

Findings 

Point 

Estimate 

Sample 

Size 

95-Percent 

Confidence Interval 

Findings on Services Overall 

Percentage of services performed by payee 85.3% 590 82.1% - 88.4% 

Percentage of services performed by independent diagnostic testing facility (IDTF), 

multispecialty group, or diagnostic radiology 88.0% 542 85.0% - 91.0% 

Percentage of services not performed by payee 14.7% 590 11.6% - 17.9% 

Percentage of reassigned services with payment reassigned within group 85.7% 417 82.0% - 89.3% 

Percentage of reassigned services with payment reassigned outside group 

Findings on Connected Services 

14.3% 417 10.7% - 18.0% 

Percentage of services that were connected services 24.8% 598 21.1% - 28.5% 

Percentage of connected services ordered by high users of magnetic resonance (MR) 54.7% 141 47.2% - 62.3% 

Percentage of services that were not connected ordered by high users of MR 33.3% 457 30.7% - 35.9% 

Percentage of connected services ordered by orthopedic surgery 27.8% 141 20.0% - 35.6% 

Percentage of services that were not connected ordered by orthopedic surgery 

Table 4 

14.6% 456 11.0% - 18.2% 

Percentage of connected services performed by multispecialty group 49.6% 125 40.3% - 58.9% 

Percentage of services that were not connected performed by multispecialty group 25.7% 417 21.0% - 30.3% 

Percentage of connected services performed by IDTF 13.4% 125 7.1% - 19.7% 

Percentage of services that were not connected performed by IDTF 39.3% 417 34.1% - 44.5% 

Percentage of connected services performed by diagnostic radiology 7.2% 125 2.4% - 12.0% 

Percentage of services that were not connected performed by diagnostic radiology 28.8% 417 24.0% - 33.6% 

Percentage of connected services performed by all other specialties 29.8% 125 21.3% - 38.3% 

Percentage of services that were not connected performed by all other specialties 

Table 5 

6.2% 417 3.7% - 8.8% 

Percentage of connected services paid to multispecialty group 50.8% 140 42.0% - 59.6% 

Percentage of services that were not connected paid to multispecialty group 26.4% 454 21.9% - 30.8% 

Percentage of connected services paid to IDTF 11.2% 140 5.7% - 16.7% 

Percentage of services that were not connected paid to IDTF 37.8% 454 32.9% - 42.7% 

Percentage of connected services paid to diagnostic radiology 7.3% 140 2.8% - 11.9% 

Percentage of services that were not connected paid to diagnostic radiology 31.0% 454 26.3% - 35.6% 

Percentage of connected services paid to all other specialties 30.7% 140 22.5% - 38.8% 

Percentage of services that were not connected paid to all other specialties 

Chart 1 

4.9% 454 2.7% - 7.1% 

Percentage of connected services billed as technical component only 33.4% 141 25.2% - 41.7% 

Percentage of services that were not connected billed as technical component only 14.0% 457 10.5% - 17.5% 

Percentage of connected services with payment reassigned 87.4% 141 81.6% - 93.2% 

Percentage of services that were not connected with payment reassigned 64.3% 456 59.4% - 69.1% 

Percentage of connected services billed through a provider other than a radiologist 63.2% 141 54.8% - 71.6% 

Percentage of services that were not connected billed through a provider other than a 

radiologist 37.8% 457 32.9% - 42.7% 

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APPENDIX~C 

Table 2: Chi-Square Tests for Connected Magnetic Resonance Services 

Findings Point Estimate 

P value 

chi-square 

Findings on Connected Services 

Percentage of connected services ordered by high users of MR 

Percentage of all other services ordered by high users of MR 

54.7% 

33.3% < .0001 

Percentage of connected services ordered by orthopedic surgery 

Percentage of all other services ordered by orthopedic surgery 

27.8% 

14.6% .0008 

Table 4 

Percentage of connected services performed by multispecialty group 

Percentage of all other services performed by multispecialty group 

49.6% 

25.7% <.0001 

Percentage of connected services performed by IDTF 

Percentage of all other services performed by IDTF 

13.4% 

39.3% <.0001 

Percentage of connected services performed by diagnostic radiology 

Percentage of all other services performed by diagnostic radiology 

7.2% 

28.8% <.0001 

Percentage of connected services performed by all other specialties 

Percentage of all other services performed by all other specialties 

29.8% 

6.2% <.0001 

Table 5 

Percentage of connected services paid to multispecialty group 

Percentage of all other services paid to multispecialty group 

50.8% 

26.4% <.0001 

Percentage of connected services paid to IDTF 

Percentage of all other services paid to IDTF 

11.2% 

37.8% <.0001 

Percentage of connected services paid to diagnostic radiology 

Percentage of all other services paid to diagnostic radiology 

7.3% 

31.0% <.0001 

Percentage of connected services paid to all other specialties 

Percentage of all other services paid to all other specialties 

30.7% 

4.9% <.0001 

Chart 1 

Percentage of connected services billed as technical component only 

Percentage of all other services billed as technical component only 

33.4% 

14.0% <.0001 

Percentage of connected services with payment reassigned 

Percentage of all other services with payment reassigned 

87.4% 

64.3% <.0001 

Percentage of connected services billed through provider other than radiologist 

Percentage of all other services billed through provider other than radiologist 

63.2% 

37.8% <.0001 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 56 
Δ APPENDIX~D 

Agency Comments 

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APPENDIX~D 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 58 
APPENDIX ~ A BANNER 2ND PAGE 

 

 

Δ ACKNOWLEDGMENTS ACKNOWLEDGMENTS 

This report was prepared under the direction of Joyce M. Greenleaf, 

Regional Inspector General for Evaluation and Inspections in the 

Boston regional office, and Russell W. Hereford, Deputy Regional 

Inspector General. 

Kenneth R. Price served as the team leader for this study. Other 

principal Office of Evaluation and Inspections staff from the Boston 

regional office who contributed include Amanda L. Pyles, Rosemary C. 

Borck, and Rose C. Lichtenstein; central office staff include Kevin 

Farber and Doris Jackson. 

 O E I - 0 1 - 0 6 - 0 0 2 6 1 P ROVIDER RELATIONSHIPS AND THE USE OF MAGNETIC RESONANCE UNDER THE MPFS 59