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An Ophthalmology Clinic in Florida: Audit of Medicare Payments for Eye Injections of Avastin, Eylea, and Lucentis

Why OIG Did This Audit

Prior OIG work found that Medicare inappropriately paid for services that were billed as being distinct or significant and separately identifiable from other services provided on the same day. Our analysis showed that in 2018, an ophthalmology clinic in Florida (the Clinic) frequently billed for other services as being distinct from or significant and separately identifiable from intravitreal (inside the eye) injections of the drugs Avastin, Eylea, and Lucentis.

Our objective was to determine whether the Clinic complied with Medicare requirements when billing for intravitreal injections of Avastin, Eylea, and Lucentis and for other services provided on the same day as the injections.

How OIG Did This Audit

Our audit covered Medicare Part B payments of $2.1 million for intravitreal injections of Avastin, Eylea, and Lucentis (and for other services provided on the same day as the injections) that the Clinic provided in 2018. We reviewed a stratified random sample of 100 beneficiary days, consisting of 543 services and drugs. (A beneficiary day consisted of all services and drugs provided on a date of service to a beneficiary in which intravitreal injections of Avastin, Eylea, or Lucentis were administered.) For each sampled beneficiary day, we provided copies of the medical records to an independent medical review contractor to determine whether the services and drugs were properly billed.

What OIG Found

The Clinic complied with Medicare requirements when billing for intravitreal injections of Avastin, Eylea, and Lucentis. (Injections of Lucentis were not included in our sample.) However, the Clinic did not always comply with Medicare requirements when billing for other services provided on the same day as the intravitreal injections (e.g., injections of an anesthesia drug). All 100 sampled beneficiary days included at least 1 service that did not comply with Medicare requirements. For 317 of the 543 services and drugs associated with the 100 sampled beneficiary days, the Clinic complied with Medicare requirements. However, for the remaining 226 services, the Clinic did not comply with the requirements: 156 services were not separately payable, and 70 services were not reasonable and necessary.

The Clinic did not have policies and procedures to ensure that it: (1) did not bill for services that were not separately payable from intravitreal injections of Avastin, Eylea, and Lucentis and (2) billed only for services that were reasonable and necessary. On the basis of our sample results, we estimated that at least $215,606 of the $2.1 million paid to the Clinic for intravitreal injections of Avastin, Eylea, and Lucentis and for other services provided on the same day as the injections was unallowable for Medicare reimbursement.

What OIG Recommends and the Clinic's Comments

We recommend that the Clinic refund to the Medicare contractor $215,606 in estimated overpayments for other services provided on the same day as intravitreal injections of Avastin, Eylea, and Lucentis. We also recommend that the Clinic implement policies and procedures to ensure that it: (1) does not bill for services that are not separately payable from intravitreal injections of Avastin, Eylea, and Lucentis and (2) bills only for services that are reasonable and necessary. The report contains one other recommendation.

The Clinic concurred in part with our first recommendation and stated that a repayment will be made but that it will appeal certain determinations. The Clinic concurred with our remaining recommendations and provided information on actions that it planned to take to address our recommendations. After reviewing the Clinic's comments, we maintain that our findings and recommendations are valid. As stated in the report, OIG audit recommendations do not represent final determinations by Medicare.

Filed under: Centers for Medicare and Medicaid Services