Florida Retina Institute Generally Met Medicare Requirements for Ophthalmology Services Provided on the Same Day as Eye Injections

Why OIG Did This Audit

• Prior OIG work found that Medicare inappropriately paid for services that were billed as being unrelated to, distinct from, or significant and separately identifiable from injections of drugs into the eye (i.e., intravitreal injections) or other services provided on the same day.
• Our analysis showed that the Florida Retina Institute (FRI) frequently billed for ophthalmology services provided on the same day as intravitreal injections, and its billing patterns were similar to those found in previous OIG audits that identified improper billing for ophthalmology services.
• This audit assessed whether FRI complied with Medicare requirements when billing for ophthalmology services provided on the same day as an intravitreal injection during calendar years 2020 and 2021.

What OIG Found

• FRI generally complied with Medicare requirements when billing for ophthalmology services provided on the same day as intravitreal injections. For 92 of the 100 sampled patient days, FRI complied with Medicare requirements for all services billed; for 8 sampled patient days it did not. Specifically, FRI incorrectly billed Medicare for services that were not medically necessary and not separately identifiable from the intravitreal injection.
• We estimated that Medicare made overpayments totaling at least $42,295 to FRI for ophthalmology services that did not comply with Medicare requirements.
• The overpayments in our sample occurred because FRI did not fully implement its policy of monitoring its claims process to promptly identify deficiencies that would affect the accuracy of its claims.

What OIG Recommends

We recommended FRI refund the $42,295 in Medicare overpayments. Although FRI disagreed with our findings, they concurred with our recommendation.

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