Practice of billing Medicare to fix droopy lids raises eyebrows

The Center for Public IntegrityMay 28, 2013 

— Aging Americans worried about their droopy upper eyelids often rely on the plastic surgeon’s scalpel to turn back the hands of time. Increasingly, Medicare is footing the bill.

The public health insurance program for people over 65 typically does not cover cosmetic surgery, but for cases in which a patient’s sagging eyelids significantly hinder their vision, it does pay to have them lifted. In recent years, though, a rapid rise in the number of so-called functional eyelid lifts, or blepharoplasty, has led some to question whether Medicare is letting procedures that are really cosmetic slip through the cracks – at a cost of millions of dollars.

As the Obama administration and Congress wrestle over how to restrain Medicare’s growing price tag, critics say program administrators should be more closely inspecting rapidly proliferating procedures like blepharoplasty to make sure taxpayers are not getting ripped off.

From 2001 to 2011, eyelid lifts charged to Medicare more than tripled to 136,000 annually, according to a review of physician billing data by the Center for Public Integrity. In 2001, physicians billed taxpayers a total of $20 million for the procedure. By 2011, the price tag had quadrupled to $80 million. The number of physicians billing the surgery more than doubled.

“With this kind of management malpractice, it’s little wonder that the (Medicare) program is in such dire shape,” said Sen. Tom Coburn, R-Okla., who is a physician. “The federal government is essentially asking people to game the system.”

Plastic surgeons say there are a number of legitimate reasons for the spike, including a tendency among the elderly to seek fixes for real medical issues they might have quietly suffered through even a decade ago. But surgeons also acknowledge an increased awareness of the surgery fueled by reality television, word-of-mouth referrals and advertising that promises a more youthful appearance. And doctors concede they face increased pressure from patients to perform eyelid lifts, even when they do not meet Medicare’s requirement that peripheral vision actually be impaired.

Thomas Scully, a former Medicare administrator under President George W. Bush, has a blunter assessment: He doubts the jump is caused by anything other than seniors seeking younger-looking eyes. “How many seniors among your friends or family have needed eyelid surgery?” he said. “I bet a hell of a lot of them at 65 say, ‘You know what, I bet I can get Medicare to pay for this.’ And I can imagine the plastic surgeons love it. If you can go to patients and say that Medicare will pay, they will do it in much larger numbers.”

Strict Medicare guidelines difficult to enforce

Quick, easy and relatively painless, eyelid surgery is one of the most popular cosmetic procedures, with patients paying out of pocket for more than 200,000 a year, according to the American Society of Plastic Surgeons. The process for purely cosmetic surgeries and Medicare-funded blepharoplasty is the same. Doctors numb the eyelids with a local anesthetic before removing fat and excess skin, often with a laser. The entire process usually takes less than 30 minutes.

Medicare reimbursement ranges from $574 to $640 per eye, depending on the setting, but the rules for Medicare coverage are firm. Purely cosmetic surgeries do not qualify. Before filing a Medicare claim, doctors are required to test a patient’s vision and document that drooping skin significantly compromises a patient’s eyesight. The exam usually involves lifting a patient’s eyelids with tape and comparing their vision results to tests performed without tape.

Unlike private insurance plans, though, Medicare does not require preauthorization of eyelid surgeries. Robert Berenson, a health policy expert at the Urban Institute and a former commissioner of the Medicare Payment Advisory Commission, has pushed for selective preauthorization for some Medicare services. But Berenson questioned whether reviewing physician records in advance would help much in the case of blepharoplasty, if surgeons have learned how to document the need for the procedure in order to work the system.

Dr. Bruce Quinn, who served as Medicare medical director of California’s Medicare Part B program from 2004 to 2008, said monitoring blepharoplasty claims is notoriously difficult. When a claim is reviewed, Quinn said, staff receives a medical record from a doctor that says a patient’s eyelids interfered with their vision, along with a photo of someone with droopy eyelids. There really isn’t anything to review, Quinn said. “It’s really hard to go much further on that,” he said.

In most cases, Medicare trusts that doctors follow the rules and pays the claims it receives. The program later reviews a small percentage of claims and sometimes attempts to recoup money. Experts say the process, derisively known as pay and chase, has allowed fraud to thrive.

Medicare does have the authority to review claims before payment, and does so in certain cases. In 2012, Palmetto GBA, a government contractor that processes and pays Medicare claims, instituted a pre-payment probe of functional eyelid surgery claims in California, Nevada, Hawaii and the Pacific Islands. In California, where the probe is complete, Palmetto denied nearly 62 percent of claims it reviewed. The majority of those errors involved insufficient information showing the eyelid surgeries were “reasonable and necessary,” a Palmetto spokesman said.

Top docs says treatments necessary

Some eyelid surgeons were willing to discuss their Medicare billing.

“I’m disappointed that I am not number one. I wish I was on top,” joked John LiVecchi, a Florida plastic surgeon who was among the top 10 billers listed in 2008 Medicare data. LiVecchi, an eyelid specialist, said his practice at St. Luke’s Cataract and Laser Institute is one of the largest in the country, which accounts for his numbers. St. Luke’s operates five offices in the Tampa Bay area.

LiVecchi, who has had an eyelid lift himself, disputes that patients are flocking to the procedure primarily with vanity in mind. Patients with droopy eyelids often don’t realize how much the droopy skin is narrowing their field of vision, he said. LiVecchi said he jokes with his patients that he doesn’t want them driving in his neighborhood until after the surgery. “It’s safer for society,” he said.

As for the cosmetic boost, LiVecchi compared eyelid surgery to removing a cancerous lump from a patient’s face. In both cases the doctor’s primary objective is keep a patient healthy, he said. A more youthful appearance is only a pleasant side effect, which he sees no problem with. “Doesn’t everybody want to look good?” he asked.

The benefits of functional eyelid surgery for some patients are documented. A 2011 study published in the journal Ophthalmology, for example, found that the surgery provided “significant improvement in vision, peripheral vision, and quality of life activities.”

Plastic surgeons interviewed said vision problems are not always the draw. Dr. Michael Migliori, the president of the American Society of Ophthalmic Plastic and Reconstructive Surgery, said he sees three or four people a day who need the surgery at his practice at Rhode Island Hospital. But he conceded he faces a lot of pressure from patients who do not qualify. “They come in begging for you to do this surgery,” Migliori said. “You get a lot of pressure to bend the rules.”

Migliori said fudging the paperwork wouldn’t be hard. “You could tell the patient to squint,” he said, regarding the requirement that the condition be documented by a photograph, and then fake the vision test. But he thinks the majority of his colleagues are honest.

The Center for Public Integrity is a nonprofit, independent investigative news outlet. For more of its stories on this topic go to publicintegrity.org.

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