Dr. Michael Migliori, president of the American Society of Ophthalmic Plastic and Reconstructive Surgery, said the Florida surgeon’s billing level might be feasible, if he was a busy eyelid specialist who performed few or no other procedures. But since the doctor also advertises breast augmentations, tummy tucks, liposuction and a variety of other general cosmetic procedures, Migliori said his billing “does seem like an awful lot.”

Ryan Stumphauzer, a former federal prosecutor in the Southern District of Florida and founding member of the Medicare Fraud Strike Force, put it more bluntly: “There is no way that is anything other than crap.”

A spokesman for the Centers for Medicare and Medicaid Services, after being shown the Center’s data analysis, declined to comment.

Guidelines difficult to enforce

Quick, easy, and relatively painless, eyelid surgery is one of the most popular cosmetic procedures, with patients paying out of pocket for more than 200,000 a year, according to the American Society of Plastic Surgeons. The process for purely cosmetic surgeries and Medicare-funded blepharoplasty is the same. Doctors numb the eyelids with a local anesthetic before removing fat and excess skin, often with a laser. The entire process usually takes less than 30 minutes, and is performed most often in doctors’ offices or outpatient surgical centers, some of which are connected to “medical spas” or “beauty clinics.”

Medicare reimbursement ranges from $574 to $640 per eye, depending on the setting, but the rules for Medicare coverage are firm. Purely cosmetic surgeries do not qualify. Before filing a Medicare claim, doctors are required to test a patient’s vision and document that drooping skin significantly compromises a patient’s eyesight. The exam usually involves lifting a patient’s eyelids with tape and comparing their vision results to tests performed without tape.

Unlike private insurance plans, though, Medicare does not require pre-authorization of eyelid surgeries. Robert Berenson, a health policy expert at the Urban Institute and former commissioner of the Medicare Payment Advisory Commission, has pushed for selective pre-authorization for some Medicare services. But Berenson questioned whether reviewing physician records in advance would help much in the case of blepharoplasty, if surgeons have learned how to document the need for the procedure in order to work the system.

Dr. Bruce Quinn, who served as Medicare medical director of California’s Medicare Part B program from 2004 to 2008, said monitoring blepharoplasty claims is notoriously difficult. When a claim is reviewed, Quinn said, staff receives a medical record from a doctor that says a patient’s eyelids interfered with their vision, along with a photo of someone with droopy eyelids. There really isn’t anything to review, Quinn said. “It’s really hard to go much further on that.”

In most cases, Medicare trusts that doctors follow the rules and pays the claims it receives. The program later reviews a small percentage of claims and sometimes attempts to recoup money. Experts say the process, derisively known as pay and chase, has allowed fraud to thrive.

Medicare does have the authority to review claims before payment, and does so in certain cases. In 2012, Palmetto GBA, a government contractor that processes and pays Medicare claims, instituted a pre-payment probe of functional eyelid surgery claims in California, Nevada, Hawaii and the Pacific Islands. In California, where the probe is complete, Palmetto denied nearly 62 percent of claims it reviewed. The majority of those errors involved insufficient information showing the eyelid surgeries were “reasonable and necessary,” a Palmetto spokesman said.