Do you ever get the sneaking suspicion everyone’s having fun but you? Everyone’s leading an exciting life? And, of course, everyone’s making more money. It’s the feeling you get when you scroll through other people’s social media feeds: “Courtney’s sharing a panini with J.Lo?! I never do anything fun.”
I wouldn’t blame ophthalmologists if they got this feeling after reading various news items from the past month.
First came the “annual insult,” also known as the proposed cut in Medicare reimbursement for 2025. While other workers get cost-of-living increases and the cost for things like staffing and utilities continue to rise, cataract surgeons’ reimbursement gets cut. The proposed decrease is around 2.8 percent.
Next came a Wall Street Journal investigative report of Medicare Advantage plans that alleged insurers were diagnosing patients with conditions they didn’t have in order to get more money from the government, because sicker patients with certain conditions are allowed more funds for their treatment.1 The story hits close to home, too, as some of the diagnoses were ophthalmic, specifically diabetic cataracts. So, you’re getting less money for removing actual cataracts, while insurers are allegedly making millions off of cataracts that don’t even exist. Makes you wonder if you’re in the wrong racket.
The Journal found that members of one particular Medicare Advantage plan were 15 times more likely to have diabetic cataracts than a patient in Medicare. “Eye doctors interviewed by the Journal said it was implausible that such a large share of UnitedHealth’s patients could have the relatively rare disease,” the article reports.
To add insult to the alleged financial injury, the paper’s analysis found that more than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts after they’d already had cataract surgery! Now, I’m no doctor—I don’t even play one on YouTube—but that just doesn’t seem possible.
All in all, the Journal reports, the government paid Medicare Advantage insurers more than $700 million from 2019 to 2021 for the historically rare diagnosis of diabetic cataracts. “Most of the diagnoses were added by insurers,” the report adds.
When all diagnoses were taken into account, the charges for diseases that patients may not have even had add up to around $50 billion.1
As has been mentioned before in this space, if the government could just eliminate the waste, and potential fraud, from its programs, then
Medicare reimbursement cuts could be reduced or even eliminated for a year or longer, giving ophthalmologists some much needed financial relief. Until then, I guess physicians will just have to operate at a “Medicare Disadvantage.”
— Walter Bethke
Editor in Chief
1. Weaver C, McGinty T, Matthews AW, Maremont M. Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated. WSJ. https://www.wsj.com/health/healthcare/medicare-health-insurance-diagnosis-payments-b4d99a5d?mod=health_trendingnow_article_pos5. Accessed July 28, 2024.
