What the OIG Wants You to Know About Spine Injections for Pain

Neck and back pain is one of the most common reasons patients visit their doctor. Of course, there are many different causes for this pain. But when the pain can be isolated to specific structures in the spine, such as the facet joints, injections are often used to treat the pain.

Treating Pain with Injections: Medical Necessity

These injections don’t come without some compliance risks. There have been recent settlements for medically unnecessary spine injections and some proactive auditing work performed by the OIG concerning their observed increase in the volume of these services. One recent settlement was announced in December of 2021. A Texas pain clinic and its affiliated ambulatory surgery center agreed to pay the United States and the State of Texas $836,702.88 to resolve allegations they violated the False Claims Act by overbilling federal healthcare programs.

Specifically, it was alleged these entities overbilled for facet joint injections, transforaminal injections, and radiofrequency ablation procedures. Spine injections are often billed with medical codes organized by spinal levels. The government alleged the defendants billed for more units or levels of these procedures than they performed. For example, the government alleged that even when a patient received only a single injection, the medical bill would claim that the patient had received two or three injections, increasing the amount paid for the procedure.

In another case, a jury convicted a Houston physician for his role in a scheme involving approximately $1.5 million in fraudulent Medicare claims, including medically unnecessary facet joint injections. According to the U.S. Department of Justice, evidence at trial showed illegal kickbacks were paid to bill Medicare for medically unnecessary facet injections, not provided or both. See more here.

Results of the OIG’s Proactive Auditing

In addition to settlements for specific cases of alleged misconduct, there has also been some proactive auditing performed by HHS OIG. In an October 2020 report published by the OIG, they determined Medicare improperly paid physicians for too many levels of facet injections. This specific audit focused on local Medicare policies, local coverage determinations, or LCDs. These policies outline the conditions under which Medicare will, or will not, cover a certain number of facet joint injections.

The local Medicare contractors (Medicare Administrative Contractors, or MACs) developed limitations of coverage that allows physicians to be reimbursed, during a rolling 12-month period, for a maximum of five sessions in which facet-joint injections are delivered to the lumbar region of the spine (lumbar spine) or the cervical and thoracic regions of the spine (cervical/thoracic spine). The OIG audited to determine if this reimbursement restriction was followed.

OIG Recommendations for CMS

For the audit period in question, OIG found the MACs in the 11 jurisdictions with a coverage limitation made improper payments of $748,555. Based on this finding, the OIG had some sweeping recommendations for CMS, including:

1. 1. 1. direct the MACs that oversee the 11 jurisdictions to recover $748,555 in improper payments made to physicians
      2. instruct the MACs to, based upon the results of this audit, notify appropriate physicians (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the physicians can exercise reasonable diligence to identify, report, and return any overpayments following the 60-day rule and identify any of those returned overpayments as having been made following this recommendation
      3. develop oversight mechanisms for the MACs to implement to prevent or detect payments to physicians for more than five facet-joint injection sessions received by beneficiaries during a rolling 12-month period in the lumbar spine or cervical/thoracic spine
      4. direct the MACs that oversee the 11 jurisdictions to review claims for facet-joint injections after the audit period to identify instances in which Medicare paid physicians for more than five injection sessions received by beneficiaries during a rolling 12-month period and recover any improper payments identified

Proactively Look at Claims and Reimbursements

CMS concurred with these OIG recommendations and described, in the report, actions that it plans to take to address these recommendations. Knowing CMS will take action consistent with these OIG recommendations should prompt compliance professionals to proactively look at their claims and reimbursement associated with facet joint injections.

To download this blog as a PDF, click the button below.