National Heritage Insurance Company: Audit of Medicare Claims by Podiatrists and Optometrists for Comprehensive Nursing Facility Assessments for Calendar Years 1995 through 1998

This final audit report presents the results of our audit of claims by podiatrists and optometrists for comprehensive nursing facility (CNF) assessments during Calendar Years 1995 through 1998. We found that podiatrists and optometrists in Northern California inappropriately billed Medicare for CNF assessment services totaling $1,628,369 and $868,027, respectively. NHIC paid $1,125,043 and $525,159 for their claims. Prior to our report, NHIC had issued guidance to optometrists and implemented edits to prevent payments to podiatrists. Therefore, we recommend that NHIC: (1) issue a reminder to podiatrists not to bill for any service they are not licensed to perform, such as CNF assessments, and (2) implement computer edits to prevent payment of CNF assessments claimed by optometrists. NHIC representatives agreed with our audit findings and recommendations, and stated it would educate its providers and pursue a prepayment edit for optometrists.