US watchdog flags $105 million in questionable vascular procedure billing

A report by the Office of the Inspector General at the US Department of Health and Human Services has identified approximately $105 million in Medicare payments for medically questionable vascular procedures. The review, which began in April 2024, flagged nearly 140 doctors across the United States with “concerning” billing patterns, noting that a small group of specialists accounted for the majority of these payments. The findings broadly confirm a 2023 ProPublica investigation into the surge of unnecessary office-based treatments, such as atherectomies, which have shifted from hospitals to private practices.

The OIG analysis focused on data from 2019 through 2023 and found that $105 million, representing about a fifth of all office-based vascular payments in 2023, was suspicious for medically unnecessary procedures. The flagged group of specialists, including interventional radiologists, vascular surgeons, and cardiologists, received an average of $3 million in medical payments each. These outlier physicians treated more than four times the average number of Medicare patients and conducted double the average number of procedures per patient compared with similar physicians.

Approximately half of the flagged doctors practiced in California and Texas. The report noted that while overall payments for these procedures have decreased, they have shifted from hospitals to physicians’ offices. This shift was partly driven by policy changes nearly two decades ago when the Centers for Medicare & Medicaid Services (CMS) attempted to rein in hospital costs by diverting certain minimally invasive procedures to outpatient facilities.

Since 2019, the CMS has identified 15 providers who received overpayments for vascular procedures. The agency has initiated a “claims analysis project” to detect physicians excessively billing for certain procedures, including atherectomies. The OIG recommended that CMS monitor billing records and work with its program integrity team to review the billing patterns of the outlier physicians.

CMS agreed with the OIG’s recommendations and stated it would consider the findings to determine next steps. The inspector general’s report stated that although determining whether these physicians engaged in abusive or fraudulent practices was not within the scope of the study, their billing patterns warrant further scrutiny.