On 22nd March 2023, the OIG completed an audit assessing the compliance of Medicare payments for spinal facet joint interventions. The motivation for this audit was due to previous instances of improper payments and overutilization risk of these interventions. The audit spanned from 1st August to 31st October 2021 and investigated the $62.2 million allocated for these procedures in 425,843 claim lines.

The objective was to verify if the physician payments aligned with Medicare guidelines. To do this, a sample of 120 intervention sessions was evaluated. The beneficiaries’ medical records were checked for adherence to billing requirements, but the medical necessity of the interventions needed to be assessed.

Results showed that not all payments adhered to Medicare’s rules. Of the checked sessions, 54 were found to be compliant, but 66 failed to meet one or more requirements, leading to improper payments totaling $18,084—the audit estimated improper payments of about $29.6 million for this period.

The billing of therapeutic facet-joint injections also raised some issues, with 33 out of 43 claims incorrectly flagged as diagnostic injections.

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Originating Article: HSS.gov | Medicare Improperly Paid Physicians an Estimated $30 Million for Spinal Facet-Joint Interventions A-09-22-03006 03-22-2023 (hhs.gov)