Objective

To determine whether Empire BlueCross properly paid hospital claims for intraocular procedures. The audit covered the period January 1, 2014 through June 30, 2019.

About the Program

The New York State Health Insurance Program (NYSHIP) provides health insurance coverage to over 1.2 million active and retired State, local government and school district employees, and their dependents. The Empire Plan is the primary health benefits plan for NYSHIP, covering nearly 1.1 million members. Empire BlueCross (Empire) administers the hospital portion of the Empire Plan.

Empire processes claims for hospital services according to contracts it negotiates with hospitals. The hospital contracts include reimbursement fee schedules for inpatient and outpatient hospital services. Hospitals may be entitled to additional payments for special items, such as implants, which are not covered by fee schedules.

Intraocular lenses are used in the treatment of cataracts – the clouding of the lens in the eye – which cause vision problems. A cataract is corrected with surgery, which frequently involves removing the clouded lens and replacing it with an intraocular lens (such as a plastic lens). Empire generally reimburses the intraocular lens as a special item implant, meaning the hospital receives an additional fee for the lens itself. If a provider corrects or adjusts the intraocular lens, the additional implant fee should not be paid. When hospitals send claims for reimbursement, in addition to general service codes, they typically include specific service codes, which helps Empire make appropriate payments. From January 1, 2014 through June 30, 2019, Empire paid over $1.5 million for 3,169 special item intraocular lens claims.

Key Finding

We reviewed the 3,169 special item intraocular lens claims paid during the audit period and found Empire paid $162,887 for 164 claims that included a specific service code that contradicted the general service code and indicated a lens had not been implanted.

Key Recommendations

• Review the $162,887 in claims identified in this audit and recover all overpayments, as warranted.
• Ensure adequate payment controls over intraocular lens claims are implemented.