I 
116TH CONGRESS 
1ST SESSION H. R. 2143 
To prevent wasteful and abusive billing of ancillary services to the Medicare 
program, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 9, 2019 
Ms. SPEIER (for herself and Ms. TITUS) introduced the following bill; which 
was referred to the Committee on Energy and Commerce, and in addition 
to the Committee on Ways and Means, for a period to be subsequently 
determined by the Speaker, in each case for consideration of such provi-
sions as fall within the jurisdiction of the committee concerned 
A BILL 
To prevent wasteful and abusive billing of ancillary services 
to the Medicare program, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Promoting Integrity 
in Medicare Act of 2019’’ or ‘‘PIMA of 2019’’. 
SEC. 2. FINDINGS; PURPOSES. 
(a) FINDINGS.—Congress finds the following: 
(1) Recent studies by the Government Account-
ability Office (GAO) examining self-referral practices 
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in advanced diagnostic imaging and anatomic pa-
thology determined that financial incentives were the 
most likely cause of increases in self-referrals. 
(2) For advanced diagnostic imaging, GAO 
stated that ‘‘providers who self-referred made 
400,000 more referrals for advanced imaging serv-
ices than they would have if they were not self-refer-
ring’’, at a cost of ‘‘more than $100 million’’ in 
2010. 
(3) For anatomic pathology, GAO found that 
‘‘self-referring providers likely referred over 918,000 
more anatomic pathology services’’ than they would 
have if they were not self-referring, costing Medicare 
approximately $69,000,000 more in 2010 than if 
self-referral was not permitted. 
(4) For radiation oncology, GAO found that in-
tensity modulated radiation therapy (IMRT) utiliza-
tion among self-referring groups increased by 356 
percent, with overall increases in IMRT utilization 
rates and spending due entirely to services per-
formed by limited-specialty groups. The GAO con-
cluded that ‘‘the higher use of IMRT by self-refer-
ring providers results in higher costs for Medicare 
and beneficiaries. To the extent that treatment deci-
sions are driven by providers’ financial interest and 
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not by patient preference, these increased costs are 
difficult to justify’’. 
(5) For physical therapy, GAO found that ‘‘in 
the year a provider began to self-refer, physical ther-
apy service referrals increased at a higher rate rel-
ative to non-self-referring providers of the same spe-
cialty’’. 
(6) Noting the rapid growth of services covered 
by the in-office ancillary services (IOAS) exception 
and evidence that these services are sometimes fur-
nished inappropriately by referring physicians, the 
Medicare Payment Advisory Commission (MedPAC) 
stated that physician self-referral of ancillary serv-
ices creates incentives to increase volume under 
Medicare’s current fee-for-service payment systems 
and the rapid volume growth contributes to Medi-
care’s rising financial burden on taxpayers and bene-
ficiaries. 
(7) The President’s Fiscal Year 2017 Budget 
includes the change to remove the four services: ad-
vanced diagnostic imaging, anatomic pathology, radi-
ation oncology, and physical therapy from the IOAS 
exception to the Stark Law and cited the change as 
generating a savings score of $4,980,000,000 over 
10 years. The nonpartisan Congressional Budget Of-
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fice’s analysis of the President’s Fiscal Year 2017 
Budget listed the change as generating a savings of 
$3,300,000,000 over 10 years. 
(8) According to the Centers for Medicare & 
Medicaid Services, a key rationale for the IOAS ex-
ception was to permit physicians to provide ancillary 
services in their offices to better inform diagnosis 
and treatment decisions at the time of the patient’s 
initial office visit. 
(9) It is necessary, therefore, to distinguish be-
tween services and procedures that were intended to 
be covered by the IOAS exception, such as routine 
clinical laboratory services or simple x-rays that are 
provided during the patient’s initial office visit, and 
other health care services which were clearly not en-
visioned to be covered by that exception because they 
cannot be performed or completed during the pa-
tient’s initial office visit. 
(10) According to a 2010 Health Affairs study, 
less than 10 percent of CT, MRI, and Nuclear Medi-
cine scans take place on the same day as the initial 
patient office visit. 
(11) According to a 2012 Health Affairs study, 
urologists’ self-referrals for anatomic pathology serv-
ices of biopsy specimens is linked to increased use 
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