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Questionable Billing for Medicare Ophthalmology Services


In 2012, 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. Since 2010, OIG has investigated over 100 providers of ophthalmology services for fraud. We did this study to determine the extent to which ophthalmology services are vulnerable to fraud, waste, and/or abuse.


We developed measures of questionable billing and used them to identify several different types of possible fraud, waste, and abuse. We examined approximately 34 million paid claims for ophthalmology services from 2012. We identified providers with unusually high billing for procedures that screen for, diagnose, evaluate, or treat wet AMD or cataracts. For providers with questionable billing, we calculated the dollar amount that Medicare paid for services associated with these measures. We also identified the metropolitan areas in which providers with questionable billing were located and the medical specialties of providers billing for ophthalmology services.


While most providers did not demonstrate questionable billing on any of our measures in 2012, 4 percent of providers billing Medicare for ophthalmology services demonstrated at least one of our nine measures of questionable billing. Overall, Medicare paid these 1,726 providers $768 million for ophthalmology services in 2012, of which $171 million was for services associated with the measures on which these providers demonstrated questionable billing. In seven metropolitan areas, the percentage of Medicare payments associated with our measures was at least twice as high as it was nationally. Medicare also paid $2 million for ophthalmology services to 821 providers that were not listed as eye care specialists in CMS databases.


There may be legitimate reasons why some of the providers demonstrated questionable billing on the measures in this report. However, providers with questionable billing warrant further scrutiny. Therefore, we recommend that the CMS (1) increase monitoring of billing for ophthalmology services, including using 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 this evaluation and conveyed by a separate memo. CMS concurred with both of our recommendations.