On November 22, the OIG of HHS released a report on its audit of payments made to physicians for co-surgery and assistant-at-surgery procedures under the Medicare Part B program. The audit covered $15.4 million paid for services performed during 2017, 2018, and 2019. The audit revealed patterns of overpayments that indicate approximately $4.9 million in improper payments were made, by OIG’s estimation.
For surgical procedures performed on the same patient during the same operative session by multiple physicians working together as co-surgeons or as a primary and assistant surgeon, CMS makes] a reduced payment to each, adjusted by a co-surgery or assistant-at-surgery modifier. However, a potential risk of overpayment arises when a modifier is not applied to the claim.
The analysis by OIG, using a stratified random sample, confirmed the OIG’s suspicion of the risk of overpayment. The OIG found that sixty-nine (69) of the one hundred (100) sampled claims did not comply with federal requirements, resulting in overpayments of $31,545. The OIG extrapolated this finding to the approximately $4.9 million in improper payments.
The OIG recommends that CMS: (1) recover applicable overpayments, (2) strengthen internal and external (with Medicare contractors) diligence and detecting mechanisms to identify and prevent improper payments, and (3) update educational materials to providers on proper billing.