An Ophthalmology Clinic in Florida: Audit of Medicare Payments for Eye Injections of Avastin, Eylea, and Lucentis. R.eview and analyze the concepts outlined. What is the issue here?

The Clinic complied with Medicare requirements when billing for intravitreal injections of Avastin, Eylea, and Lucentis. (Injections of Lucentis were not included in our sample.) However, the Clinic did not always comply with Medicare requirements when billing for other services provided on the same day as the intravitreal injections (e.g., injections of an anesthesia drug). All 100 sampled beneficiary days included at least 1 service that did not comply with Medicare requirements. For 317 of the 543 services and drugs associated with the 100 sampled beneficiary days, the Clinic complied with Medicare requirements. However, for the remaining 226 services, the Clinic did not comply with the requirements: 156 services were not separately payable, and 70 services were not reasonable and necessary.

The Clinic did not have policies and procedures to ensure that it: (1) did not bill for services that were not separately payable from intravitreal injections of Avastin, Eylea, and Lucentis and (2) billed only for services that were reasonable and necessary. On the basis of our sample results, we estimated that at least $215,606 of the $2.1 million paid to the Clinic for intravitreal injections of Avastin, Eylea, and Lucentis and for other services provided on the same day as the injections was unallowable for Medicare reimbursement

https://oig.hhs.gov/oas/reports/region9/91903025.pdf