HHS inspector general says millions given by Medicare for nonexistent eye procedures

The Department of Health and Human Services inspector general has uncovered $22 million in payments made to doctors who attempted to defraud the Medicare program by billing HHS for services and treatments they did not perform.

Washington Examiner:

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.

Studies estimate that up to 10% of all Medicare funds are given to doctors and providers who commit fraud, or spent on banned procedures.  If accurate, that would be $58 billion in waste and fraud throughout the entire program.  You're never going to eliminate all of the fraud, but certainly HHS can do better to root it out.