OIG Flags Questionable Billing for Ophthalmology Services Totaling $171 Million in Medicare Pay-Outs to Various Providers

Thursday, February 4, 2016
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The Department of Health and Human Services Office of Inspector General (OIG) flagged various Medicare providers as having questionable billing practices for ophthalmology services rendered in 2012. The services billed for and flagged as questionable include the diagnosis and treatment of wet age-related macular degeneration (wet AMD) and complex cataract surgery. Medicare paid a total of $171 million for the services now warranting further scrutiny according to OIG.

Questionable Does Not Necessarily Mean Improper.

OIG acknowledged that flags for questionable billing do not necessarily mean impropriety has occurred. OIG utilizes nine measures when considering potential indicators of fraud and abuse. If questionable billing is demonstrated on at least one of these nine measures, then it is flagged for further review.

In 2012, Medicare paid $6.7 billion to 44,960 providers for wet AMD and cataract-related services. Approximately 4% of those providers, or 1,726, demonstrated questionable billing on at least one of the nine measures. OIG reported that another 4% of that number of providers exceeded the threshold for two measures and nine providers exceeded thresholds for three, four or five measures.

While these findings do not conclusively establish the commission of fraud, OIG has advised the Centers for Medicare and Medicaid Services (CMS) to review the identified healthcare providers and take action if necessary.

To read one of our previous blog posts on the OIG increasingly issuing investigative subpoenas to ophthalmologists, click here.

Unusually High Levels of Billing for a Specific Service May Indicate Fraud.

While only about 15% of providers demonstrated questionable billing for wet AMD treatments, Medicare payments for these services totaled more than half ($91 million) of all payments associated with questionable billing. Many providers were also indicated in questionable billing for complex cataract surgery. However, the total Medicare payments for the cataract procedures at $39 million was much lower than that of wet AMD treatments.

OIG identified 355 providers with unusually high billing related to the diagnosis of wet AMD costing Medicare a total of $23 million. Another 586 providers were reported with unusually high billing for ophthalmology claims using certain modifiers totaling $18 million in Medicare payments.

The OIG observed that when providers bill for certain procedures at unusually higher levels than their peers it may be because such services are not medically necessary, thereby indicating possible fraudulent activity. On the other hand, our experience in defending ophthalmologists and optometrists has shown that it might also just be a case of a certain physician being the best around in performing that procedure.

More Troubling Trends in OIG’s Report.

According to OIG’s report, and in comparison to the national average of 2.6%, seven metropolitan areas had at least double the percentage of Medicare payments associated with the measures of questionable billing. Miami, Florida made the list as one of the seven areas, along with: Huntington, West Virginia; Vineland, New Jersey; Salisbury, Maryland; Grand Rapids, Michigan; Fresno, California; and Cincinnati, Ohio.

Furthermore, OIG indicated that $2 million paid by Medicare for ophthalmology services performed, was paid to 821 various providers that were not listed as eye specialists in government databases. OIG asserts that this calls into question the quality and appropriateness of services rendered by these individuals if, in fact, they were not properly trained to perform such services.

To read the full report by the OIG, click here.


Are you an ophthalmologist who has been flagged by OIG for questionable billing? Please leave any thoughtful comments below.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent ophthalmologists and other healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

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“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
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