Medicare Improperly Paid Physicians an Estimated $15.2 Million for Sacroiliac Joint Injections OAS-25-09-021

Why OIG Did This Audit

• Sacroiliac joint injections (a type of spinal pain management service) are covered under Medicare Part B when medically reasonable and necessary.
• In two prior audits of facet-joint interventions (another type of spinal pain management service), we found that Medicare paid for more than 50 percent of the sampled services that did not comply with one or more Medicare requirements.
• Because we identified a high risk of noncompliance with facet-joint interventions, we conducted this nationwide audit to determine whether Medicare paid physicians for sacroiliac joint injections in accordance with Medicare requirements and guidance.

What OIG Found

• Of the 100 sampled sessions, 72 did not comply with Medicare requirements. In addition, of the 100 sampled sessions, physicians' billing of 25 sessions did not meet Medicare guidance.
• On the basis of our sample results, we estimated that Medicare improperly paid $15.2 million for 134,526 of 186,842 total sessions from October 1, 2023, through September 30, 2024. We also estimated that physicians incorrectly billed 46,711 sessions as therapeutic injections when they should have been billed as diagnostic injections.
• Oversight provided by CMS and the Medicare Administrative Contractors (MACs) was not sufficient to ensure compliance with Medicare requirements and guidance.

What OIG Recommends

We made three recommendations to CMS, including that it work with the MACs to develop education that is specific to the Medicare requirements, guidance for sacroiliac joint injections to prevent improper Medicare payments, and solutions to prevent the incorrect billing of diagnostic injections as therapeutic injections. The full recommendations are in the report.

CMS concurred with our first and second recommendations, but did not concur with our third recommendation.