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Medicare Paid $22 Million in 2012 for Potentially Inappropriate Ophthalmology Claims


Medicare paid approximately $8.2 billion in 2012 to screen for, diagnose, evaluate, or treat cataracts, wet age related macular degeneration (wet AMD), and glaucoma. Medicare uses a combination of national and local coverage requirements to determine whether it will cover services for these conditions. However, recent investigations have found that some ophthalmology services for these conditions are vulnerable to fraud, waste, and/or abuse.


We reviewed Medicare claims data from 2012 and identified approximately 49 million claims that 46,456 providers submitted for screening for, diagnosing, evaluating, or treating cataracts, wet AMD, and glaucoma. We also reviewed the Medicare coverage database and identified 4 national requirements and 2 local coverage requirements that specified when Medicare should and should not cover certain ophthalmology procedures associated with these conditions. Then we analyzed these claims to identify those that were potentially paid inappropriately based on these requirements. We did not review the medical records for any claims to determine if exceptions to the requirements were documented and appropriate. We also calculated the total amount that Medicare paid each provider for these claims, and we determined which contractor paid these claims.


Medicare paid $22 million for ophthalmology claims in 2012 that were potentially inappropriate, according to national and local coverage requirements. Specifically, $14 million was paid despite the presence of national requirements that were designed to prevent these payments. Similarly, $8 million was paid despite the presence of local coverage requirements that were designed to prevent these payments. Additionally, two of eleven Medicare contractors paid a disproportionate amount of the potentially inappropriate Medicare payments.


We recommend that CMS (1) implement additional claims processing edits or improve existing edits to ensure claims are paid appropriately and (2) determine the appropriateness of ophthalmology claims identified in this report and take appropriate action. CMS concurred with both of our recommendations.