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Are feds targeting ophthalmology clinics for Medicare overpayments?

by | May 14, 2021 | Medicare Overpayment |

There are circumstances that result in a surgeon needing to perform two procedures in one day. Unfortunately, unless certain criteria are met, the surgeon in this position could find themselves accused by the feds of fraudulent billing practices.

Case example: OIG accuses ophthalmologist of double dipping

The United States Department of Health and Human Services Office of the Inspector General (OIG) recently released a Report in Brief summarizing an investigation of an ophthalmologist. The ophthalmologist was under investigation for inappropriate billing practices because the clinic where he worked filed claims for different procedures on the same patient on the same day.

What really happened?

The government was concerned about the clinic’s billing practices. They investigated payments made for certain treatments when the same patient had received other treatments earlier that same day. The OIG states that the clinic “generally complied” with Medicare billing requirements and that the medical director’s lack of experience with billing practices likely contributed to the error. The feds are now demanding the clinic repay almost $400,000.

The important takeaway from this case is the fact that the OIG also states that this audit is “part of a series of audits of intravitreal injections and related services.” Is the government targeting ophthalmologists? It appears that if nothing else, there is at least an increased likelihood of an audit for those within this niche area of healthcare.

What does this mean for other healthcare practitioners?

The feds continue to crackdown on allegations of fraudulent billing and appear to have a particular focus on ophthalmology clinics. As a result, those who run these types of clinics are wise to conduct an audit and make sure the clinic follows applicable regulations. If not, make changes. The best defense to these types of allegations is often a strong compliance program. Showing that the clinic take steps to address these issues can help reduce the risk of similar charges and can build a stronger defense in the event the clinic or physicians who practice there find themselves in the government’s crosshairs.

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