OIG identifies $171 million in questionable billing tied to ophthalmology services

Four percent of ophthalmologists demonstrated questionable billing habits in 2012, leading to $171 million in potentially inappropriate Medicare payments, according to a report released by the Office of Inspector General (OIG).

Although the OIG admitted there may be legitimate reasons for some instances of questionable billing, the high number of claims warrants additional oversight from the Centers for Medicare & Medicaid Services (CMS). Specifically, the OIG recommended that CMS review ophthalmology billing practices and take appropriate action against those providers identified in the OIG report.

The report comes at a time when several ophthalmologists are wrapped up in multi-million dollar fraud allegations. Most prominently, Florida ophthalmologist Salomon Melgen is facing a 76-count indictment for performing unnecessary procedures on patients with age-related macular degeneration (ARMD), leading to $105 million in fraudulent Medicare payments. Melgen is also facing separate corruption charges stemming from his relationship with Sen. Robert Menendez (D-N.J.).  

Earlier this month, another trial kicked off against a Florida ophthalmologist who was facing charges that that he billed Medicare $7 million for patients misdiagnosed with ARMD.

The nine measures used by the OIG to identify instances of questionable billing focused specifically on providers with unusually high billing for procedures to treat ARMD and cataracts. Auditors found $91 million in Medicare payments were associated with questionable ARMD procedures.

Additionally, the OIG determined that seven metropolitan areas had questionable billing rates that were twice as high as the national average. In Miami, 52 ophthalmologists contributed to $21.2 million in questionable billing. Medicare also paid $2 million to more than 800 providers across the country that were not listed as eye specialists in the CMS database.

For more:
- read the OIG report