Medicare Could Have Saved up to $20 Million Over 5 Years if CMS Oversight Had Been Adequate To Prevent Payments for Medically Unnecessary Cholesterol Blood Tests

A prior OIG audit found that Medicare paid providers that had billed for medically unnecessary laboratory tests. Our preliminary review of Medicare claims identified providers that billed for direct-measurement, low-density lipoprotein (LDL) cholesterol tests (direct LDL tests) and lipid panels (a blood test that reports four measures of lipids, including LDL cholesterol) for the same beneficiary on the same date of service; some of these providers billed the direct LDL test every time they billed the lipid panel. These claims were at risk of noncompliance with Medicare requirements because, according to the Centers for Medicare & Medicaid Services (CMS), billing for a direct LDL test in addition to a lipid panel, while sometimes medically necessary, should happen with only limited frequency.Our objective was to determine whether payments made to providers for direct LDL tests that were billed in addition to lipid panels for the same beneficiary on the same date of service complied with Medicare requirements.Our audit covered Medicare Part B payments of about $35 million for direct LDL tests that were billed in addition to lipid panels for the same beneficiary on the same date of service and that had dates of service from 2015 through 2019 (audit period).