Report Materials
Why OIG Did This Audit
- OIG data analysis identified Medicare Part B payments made to optometrists for high-level evaluation and management (E/M) services not usually billed by optometrists.
- For 2021 through 2023 (audit period), Medicare paid $4.7 million to 200 optometrists for E/M services for moderate to highly complex subsequent nursing facility care. The top 15 optometrists accounted for 72 percent of those payments.
- This audit examined whether the 15 optometrists complied with Medicare requirements when billing for services at nursing facilities.
What OIG Found
- CMS reimbursed selected optometrists for Part B services that were not billed in accordance with Medicare requirements. All 225 of the enrollees we sampled had associated claim lines of service that did not meet Medicare documentation or coding requirements. All 399 lines of services billed as high-level E/M codes for the sampled enrollees did not meet Medicare requirements.
- We estimated that Medicare overpaid the selected optometrists at least $3 million for E/M services during our audit period.
- CMS did not perform any claim reviews of optometrists’ billing and did not have system edits in place to prevent the billing of these codes.
What OIG Recommends
We made three recommendations to CMS, including that it recover the portion of the $3 million in estimated overpayments that are within the 4-year reopening period, increase claim reviews, and develop system edits to prevent the incorrect billing of services. The full recommendations are in the report.
CMS concurred with two recommendations. CMS did not fully concur with the third recommendation to increase claim reviews and develop system edits.
26-A-05-015.01 to CMS - Open Unimplemented
Update expected on
05/31/2026
We recommend that the Centers for Medicare & Medicaid Services collaborate with CMS contractors to review all claims submitted by the 15 selected optometrists to determine compliance with Medicare requirements and recover the portion of the $3,059,204 in estimated overpayments made to those optometrists during our audit period that are within the 4-year reopening period.
26-A-05-015.02 to CMS - Open Unimplemented
Update expected on
05/31/2026
We recommend that the Centers for Medicare & Medicaid Services instruct the CMS contractors to notify, as the contractors deem appropriate, providers in our sample that received an overpayment(s) to consider conducting one or more internal audits or investigations based on the risks identified by this audit to identify any similar overpayments the provider might have received and return any identified funds to the Medicare program.
26-A-05-015.03 to CMS - Open Unimplemented
Update expected on
05/31/2026
We recommend that the Centers for Medicare & Medicaid Services instruct CMS contractors to provide training and guidance that are specific to Medicare requirements for billing optometrist services provided in nursing facilities.
26-A-05-015.04 to CMS - Open Unimplemented
Update expected on
05/31/2026
We recommend that the Centers for Medicare & Medicaid Services instruct CMS contractors to increase claim reviews of optometrists' E/M services.
26-A-05-015.05 to CMS - Open Unimplemented
Update expected on
05/31/2026
We recommend that the Centers for Medicare & Medicaid Services instruct CMS contractors to develop system edits to prevent the incorrect billing of E/M services.
View in Recommendation Tracker
–
Notice
This report may be subject to section 5274 of the National Defense Authorization Act Fiscal Year 2023, 117 Pub. L. 263.