Medicare Audit Finds $15.2 Million in Improper Payments for Sacroiliac Joint Injections

The U.S. Department of Health and Human Services Office of Inspector General (OIG) has found that Medicare made an estimated $15.2 million in improper payments for sacroiliac joint injection services between October 2023 and September 2024.

The audit reviewed whether Medicare Part B payments for these spinal pain management services followed Medicare coverage requirements and billing rules. OIG found that a significant number of sampled sessions did not meet required standards.

Medicare Audit Reviewed More Than 186,000 Injection Sessions

Sacroiliac joint injections are medical procedures used to help manage certain types of spinal pain and improve movement. Medicare Part B covers these services when they are considered medically reasonable and necessary.

For the audit, OIG reviewed Medicare payments for 186,842 injection sessions during the period from October 1, 2023, through September 30, 2024. Medicare had paid approximately $22 million for these services during the audit period.

OIG selected a sample of 100 sessions to review documentation and billing compliance. The audit found that 72 of those sessions did not comply with one or more Medicare requirements.

Billing Errors and Documentation Issues Led to Improper Payments

According to OIG, some claims did not meet Medicare requirements related to coverage and documentation. In addition, 25 sampled sessions did not follow Medicare billing guidance.

The audit found that some injections were incorrectly billed as therapeutic injections when they should have been classified as diagnostic injections.

Based on the sample results, OIG estimated that 46,711 sessions nationwide may have been incorrectly billed under the wrong injection category.

Although this incorrect classification did not change the payment amount physicians received, OIG noted that inaccurate billing could affect whether Medicare beneficiaries receive the maximum number of medically necessary injection sessions allowed during a 12-month period.

OIG Recommends Stronger Medicare Billing Oversight

OIG recommended that the Centers for Medicare & Medicaid Services (CMS) work with Medicare Administrative Contractors (MACs) to improve provider education and create clearer guidance for sacroiliac joint injection billing requirements.

The recommendations are aimed at preventing future improper payments and reducing errors related to diagnostic and therapeutic injection billing.

CMS agreed with two of OIG’s recommendations but did not agree with the recommendation related to preventing incorrect billing classifications.

What This Means for Medicare Beneficiaries

The audit does not change Medicare coverage rules for patients receiving sacroiliac joint injections. The findings are focused on provider billing practices and Medicare payment accuracy.

However, the report highlights the importance of accurate documentation and billing compliance within the Medicare system. Stronger oversight may lead to additional education and review processes for healthcare providers that submit Medicare claims.

The Bottom Line

A federal OIG audit found that Medicare may have improperly paid an estimated $15.2 million for sacroiliac joint injection services because many reviewed claims did not meet Medicare requirements or billing guidance. CMS is expected to work with Medicare contractors to improve provider education and reduce future payment errors.

FAQs

1. What did the Medicare audit find?

The Medicare audit found that the program may have improperly paid an estimated $15.2 million for sacroiliac joint injection services between October 2023 and September 2024 because many claims did not meet Medicare requirements or billing guidance.

2. Who conducted the Medicare audit?

The audit was conducted by the U.S. Department of Health and Human Services Office of Inspector General (OIG) to review whether Medicare payments followed required coverage and billing rules.

3. What are sacroiliac joint injections?

Sacroiliac joint injections are medical procedures used to help manage certain types of spinal pain and improve movement. Medicare Part B covers these services when they are considered medically necessary.

4. How many Medicare sessions were reviewed?

OIG reviewed a sample of 100 sessions from a total of 186,842 sacroiliac joint injection sessions during the audit period.

5. How many sessions failed Medicare requirements?

According to the OIG report, 72 out of the 100 sampled sessions did not comply with one or more Medicare requirements.

6. Did the audit accuse doctors of fraud?

No. The report identified improper payments and billing compliance issues. It did not state that all providers committed fraud.

7. Could this affect Medicare patients?

The audit does not change Medicare coverage rules for patients. It focuses on provider billing practices and improving payment accuracy within the Medicare system.

8. What did OIG recommend to CMS?

OIG recommended that CMS work with Medicare Administrative Contractors to improve provider education, clarify billing guidance, and reduce future improper payments.

9. What is CMS’s response to the recommendations?

CMS agreed with two of OIG’s recommendations but did not agree with the recommendation related to preventing incorrect billing classifications.

10. Why is this Medicare audit important?

The audit highlights the need for accurate documentation, proper billing practices, and stronger oversight to ensure Medicare funds are used correctly.