Medicare spent $22.3 million for “potentially inappropriate” ophthalmology tests and treatments in 2012, according to the Department of Health and Human Services inspector general.
The federal healthcare program paid $8.2 billion overall that year for eye-related claims. Most of the money went to diagnosing and treating cataracts, glaucoma and wet age-related macular degeneration, the report said.
The IG identified a total of six federal and local requirements that outline when Medicare should or should not cover certain procedures related to the disorders.
Federal requirements apply to all Medicare beneficiaries and the contractors that process their claims, while local requirements can be implemented by individual contractors.
For example, at the national level, Medicare covers a cataract surgery that removes the eye’s failing natural lens and replaces it with a synthetic one. The program will only pay for one such surgery per eye under federal requirements because the eye’s natural lens can never grow back.
Despite the fact that multiple cataract surgeries on the same eye are “medically impossible,” Medicare paid $8.6 million for more than 10,000 such procedures in 2012.
“This includes one provider whom Medicare paid $59,455 for 69 surgeries — the most of any provider — on eyes that already had cataracts removed,” the IG said.
The program shelled out $14 million for claims that were specifically banned under federal guidelines and $8 million for claims banned under local ones, the report said.
Most of the 46,456 providers who filed ophthalmology claims in 2012 received no potentially fraudulent payments, the report noted. Only 237 received questionable payments of $10,000 or more, and only 12 took home $100,000 or more of such payments, the report said.
Those 12 providers soaked up 14 percent, or $3 million, of the potentially inappropriate ophthalmology payments, the report said.
Flaws in Medicare’s ophthalmology services — from reimbursements for wet AMD treatments that were unnecessarily expensive to services that weren’t performed by an eye doctor or even by a qualified professional — have persisted for years, according to the IG.
The watchdog said “recent investigations have found that some ophthalmology services for these conditions are vulnerable to fraud, waste, and/or abuse.” It cited several other examples of ophthalmology fraud, such as a single Philadelphia eye doctor who was convicted in 2011 after submitting $4.5 million in false claims.
However, the IG noted that because its staff did not review medical records as part of its evaluation, some of the claims it deemed inappropriate could have had documentation supporting their necessity.
Go here to read the full HHS IG report.
