SELF-REFERRAL IN PRIVATE OFFICES FOR IMAGING STUDIES PERFORMED IN PENNSYLVANIA-BLUE-SHIELD SUBSCRIBERS DURING 1991

PURPOSE: To define the frequency of physician self-referral for diagnostic imaging studies. MATERIALS AND METHODS: High-volume radiographic (n = 65) and ultrasound (US) (n = 29) procedural codes in claims filed by Pennsylvania Blue Shield subscribers were analyzed to determine private-office (nonhospital) utilization of these examinations by radiologists and nonradiologists during 1991. A total of 787,703 radiographic and 159,281 US claims were filed. RESULTS: Nonradiologists self-referred 550,878 radiographic examinations (69.9%) and 99,931 US examinations (62.7%). Patterns of utilization varied considerably by anatomic category: The imaging studies with the highest rates of utilization by nonradiologists were skeletal radiography, vascular US, and obstetric and pelvic US. Aggregate reimbursement allowance by Pennsylvania Blue Shield for all examinations in these 94 codes was approximately $68 million, of which $44 million (65%) went to nonradiologists. CONCLUSION. These data indicate that widespread self-referral for imaging studies occurs in nonradiologists' private-office practices and thereby raise concern about the potential for overutilization.