OIG, Medicare Payments and Pain Management Procedures

As part of the OIG 2008 Work Plan, the OIG reviewed Medicare payments for interventional pain management procedures in connection with Section 1862(a)(1)(A) of the Social Security Act, which requires that services must be medically necessary. The OIG noted that interventional pain management was a growing specialty and that Medicare paid almost $2 billion for interventional procedures in 2005. The review was to focus on the appropriateness of payments for the procedures.

In September of 2008, the OIG issued a report on “Medicare Payments for Facet Joint Injection Services” wherein they found that 63% of facet joint injection services allowed by Medicare in 2006 did not meet Medicare program requirements, resulting in $96 million in improper payments. Based on the review, the OIG recommended that CMS should:

1. Strengthen program safeguards to prevent improper payment for facet joint injections;
2. Clarify billing instructions for bilateral services; and 3. Take appropriate action regarding the undocumented, medically unnecessary, and miscoded services identified in the sample.

Of particular note, CMS agreed with the OIG recommendation to clarify instructions and to take appropriate action on services paid in error in the sample.

This report highlights the importance of compliance in the pain management arena as pain management procedures may continue to be a focus of potential scrutiny in 2009. Given the report findings, pain management physicians may also experience Medicare auditing activity with regard to facet joint injections and/or other pain management procedures. You can obtain a copy of the OIG report by visiting www.oig.hhs.gov/oei/reports/oei-05-07-00200.pdf

For more information, please call Abby Pendleton, Esq., Robert Iwrey, Esq., Adrienne Dresevic, Esq., Carey F. Kalmowitz, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510, visit The HLP website’s Anesthesia and Pain page, or visit The HLP website.

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