On September 15, 2015, OIG released a report examining the extent to which ophthalmology services are vulnerable to fraud, waste, and abuse. According to OIG, Medicare paid $6.7 billion to 44,960 providers for ophthalmology services that screen for, diagnose, evaluate, or treat two prominent eye conditions: wet age-related macular degeneration (wet AMD) and cataracts. To perform the review, OIG examined approximately 34 million paid claims for ophthalmology services from 2012. OIG identified providers with “unusually high billing” for procedures that screen for, diagnose, evaluate, or treat wet AMD or cataracts.
According to the report, although most providers did not demonstrate questionable billing for any of OIG’s measures in 2012, four percent of providers billing Medicare for ophthalmology services demonstrated at least one of OIG’s nine measures of questionable billing. OIG recommends that the CMS (1) increase monitoring of billing for ophthalmology services, including utilizing measures of questionable billing similar to those used in this review, and (2) review and take appropriate action regarding providers with questionable billing identified by OIG’s evaluation. CMS concurred with both of OIG’s recommendations.
The OIG report is available here.