CMS Paid $22 Million in Inappropriate Medicare Claims
Medicare paid $22 million for ophthalmology medicare claims in 2012 that were potentially inappropriate.
- The Department of Health and Human Service (HHS) Office of Inspector General (OIG) released the results of its auditon the Centers for Medicare & Medicaid Services (CMS) to determine if Medicare coverage payments of approximately $8.2 billion in 2012 to screen for, diagnose, evaluate, or treat cataracts, wet age-related macular degeneration (wet AMD), and glaucoma were correct. During this audit it was discovered Medicare paid $22 million for ophthalmology medicare claims in 2012 that were potentially inappropriate, according to national and local coverage requirements.
Medicare uses a combination of national and local coverage requirements to determine whether certain ophthalmology services are covered. National requirements are created at the Federal level and apply to all Medicare beneficiaries and claims processing contractors. In the absence of specific national requirements, claims processing contractors may create their own local coverage requirements about what services to cover.
Medicare may still pay for claims that do not meet the specifications outlined in national or local coverage requirements if additional documentation adequately explains the medical need for the claim. Medicare covers procedures to screen for, diagnose, evaluate, or treat many eye conditions. However, the three eye conditions for which Medicare pays the most each year are cataracts, wet AMD, and glaucoma.
Medicare paid approximately $8.2 billion for all services that screen for, diagnose, evaluate, or treat cataracts, wet AMD, and glaucoma. Recent investigations have found that certain ophthalmology services are vulnerable to fraud, waste, and/or abuse.
However, it was discovered that Medicare paid $22 million for ophthalmology medicare claims that were potentially inappropriate. Specifically, $14 million was paid despite the presence of national requirements that were designed to prevent these payments. Similarly, $8 million was paid despite the presence of local coverage requirements that were designed to prevent these payments. Additionally, two of eleven Medicare contractors paid a disproportionate amount of the potentially inappropriate Medicare payments.
“Our results demonstrate vulnerabilities in Medicare’s oversight and enforcement of its national and local coverage requirements.” the report reads.
The OIG recommends that CMS implement additional claims processing edits or improve existing edits to ensure claims are paid appropriately. The OIG also recommends that CMS determine the appropriateness of ophthalmology claims that the OIG identified as being possibly incorrectly paid and take appropriate action.
The OIG clarified that CMS should ensure that its claims processing edits should prevent payment for cataract surgeries on eyes of beneficiaries that have already had their natural lens removed. The edits should also prevent payment for ocular photodynamic therapy claims in which both steps of treatment were not billed as performed on the same day.
The CMS agreed with both of the OIG’s recommendations. CMS also expressed that it is working on implementing a comprehensive strategy to combat fraud, waste, and abuse in Medicare. The CMS plans to include educating providers on appropriate billing for services and improving its centralized portal that provides contractors and law enforcement with access to Medicare data and analytic tools in its strategy.
