Eye Doctor on Hook|for Overbilling Medicare

     MIAMI (CN) – An eye doctor cannot challenge the government’s conclusion that he overbilled Medicare by almost $9 million, a federal judge ruled.
     Vitreo Retinal Consultants of the Palm Beaches is a single-physician ophthalmology practice that serves Medicare beneficiaries in West Palm Beach, Fla.
     A 2008 audit of the practice revealed that Vitreo overbilled Medicare for the cost of Lucentis, a drug used to treat neovascular age-related macular degeneration, an eye disease that causes vision loss. The auditor found that Vitreo had administered a single vial of the drug to up to three patients, contrary to Food and Drug Administration recommendations and insurance coverage determinations, which said the drug was designed for single use.
     The practice overbilled Medicare for Lucentis by nearly $9 million in 2007 and 2008, according to the audit.
     An administrative law judge and the Medicare Appeals Council agreed that Vitreo had improperly multi-dosed the single-use injection and overbilled for it.
     After Vitreo appealed to Federal Court, U.S. District Judge Marcia Cooke upheld the Secretary of Health and Human Services’ overpayment determination last year, finding that it relied on substantial evidence and did not violate plaintiff’s due-process rights.
     The FDA-approved instructions in the Lucentis package state that each vial should be used to treat a single eye on a single patient. Health and Human Services properly relied on FDA-approved labeling information to determine the acceptable standard of care for the drug’s administration, the court found.
     Insurance coverage determinations for Lucentis and the manufacturer’s explanation of Lucentis dosing also support the conclusion that the injection was designed for single use. The agency reasonably relied on instructions from the manufacturer, which is the most authoritative source of information on Lucentis, Cooke noted.
     Moreover, in determining the proper administration of Lucentis, the agency relied on a Centers for Disease Control and Prevention warning that single-dose vials should never be used on multiple patients, according to the court’s September 2014 ruling.
     Cooke refused to reconsider the decision earlier this month, finding that Vitreo failed to bring new evidence or point to any clear errors of judgment.
     Vitreo also failed to show that the agency exceeded its authority under the Medicare Act by retroactively applying a new Medicare reimbursement policy to the practice’s billing for Lucentis, the April 10 order added.
     Representatives of Vitreo Retinal Consultants did not immediately respond to a request for comment.

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