Introduction

Aging Americans worried about their droopy upper eyelids often rely on the plastic surgeon’s scalpel to turn back the hands of time. Increasingly, Medicare is footing the bill.

Yes, Medicare. The public health insurance program for people over 65 typically does not cover cosmetic surgery, but for cases in which a patient’s sagging eyelids significantly hinder their vision, it does pay to have them lifted. In recent years, though, a rapid rise in the number of so-called functional eyelid lifts, or blepharoplasty, has led some to question whether Medicare is letting procedures that are really cosmetic slip through the cracks — at a cost of millions of dollars.

As the Obama administration and Congress wrestle over how to restrain Medicare’s growing pricetag, critics say program administrators should be more closely inspecting rapidly proliferating procedures like blepharoplasty to make sure taxpayers are not getting ripped off.

From 2001 to 2011, eyelid lifts charged to Medicare more than tripled to 136,000 annually, according to a review of physician billing data by the Center for Public Integrity. In 2001, physicians billed taxpayers a total of $20 million for the procedure. By 2011, the price tag had quadrupled to $80 million. The number of physicians billing the surgery more than doubled.

“With this kind of management malpractice, it’s little wonder that the [Medicare] program is in such dire shape,” said Sen. Tom Coburn, R-Okla., who is also a physician. “The federal government is essentially asking people to game the system. Every dollar we spend on cosmetic surgery that isn’t necessary is a dollar that can’t be used to shore up the program for people who need it the most.”

Plastic surgeons say there are a number of legitimate reasons for the spike, including a tendency among the elderly to seek fixes for real medical issues they might have quietly suffered through even a decade ago. But surgeons also acknowledge an increased awareness of the surgery fueled by reality television, word-of-mouth referrals, and advertising — often including dramatic before-and-after photographs — that promises a more youthful appearance. And doctors concede they face increased pressure from patients to perform eyelid lifts, even when they do not meet Medicare’s requirement that peripheral vision actually be impaired.

Thomas Scully, former Medicare administrator under George W. Bush, has a blunter assessment; he doubts the jump is caused by anything other than seniors seeking younger-looking eyes. “How many seniors among your friends or family have needed eyelid surgery?” he said. “I bet a hell-of-a-lot of them at 65 say, ‘You know what, I bet I can get Medicare to pay for this.’ And I can imagine the plastic surgeons love it. If you can go to patients and say that Medicare will pay, they will do it in much larger numbers.”

Florida surgeon bills Medicare for more than 2,200 eye surgeries a year

Surgeons who bill Medicare for large numbers of eyelid surgeries dot a map of the United States. Yet 11 of the 20 highest billers in 2008 were in Florida, which is both an elderly mecca and the country’s foremost magnet for questionable Medicare billing.

Among the top surgeons, the data show a South Florida doctor billed Medicare more than $800,000 in 2008 for about 2,200 eyelid lifts. That’s an average of six a day, including weekends. This same doctor was also a top biller in 2006 and 2007.

The Center is barred from naming the Florida surgeon. A 1979 federal court injunction blocks the Department of Health and Human Services from publically releasing doctor’s names in conjunction with specific Medicare billing information. The Center sued HHS to obtain the Medicare data but as a condition for obtaining it, signed an agreement not to publish the names of individual doctors, unless they agreed to discuss their billing histories. After repeated calls for comment, and a fax including the billing referenced by the Center, the Florida physician’s office assistant said he would not talk “due to prior engagements.”

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 on whether agency officials had noticed the dramatic uptick in blepharoplasty or taken any measures to ensure the billed procedures are legitimate.

Strict Medicare 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. “I am sure there are some patients who are hampered by eyelids drooping. And I’m sure that many of them are not and it’s a cosmetic reason,” Berenson said. But the doctors, he added, “have probably gotten very skilled at knowing how to document that something is not cosmetic.”

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.”

It’s also difficult and expensive to take blepharoplasty cases to court if a provider is suspected of fraudulent billing, Quinn said. To make a case, the prosecution requires patient testimony and boxes of records, a bar that is hard to meet. Quinn said although the explosion of blepharoplasty caught his attention in California, it was “pretty slippery to get a handle on.”

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.

Top docs says treatments necessary

Unlike the top biller in South Florida, some eyelid surgeons were willing to discuss their Medicare billing. “I’m disappointed that I am not number one. I wish I was on top,” joked John LiVecchi, a Florida plastic surgeon who was among the top ten billers listed in 2008 Medicare data. LiVecchi, an eyelid specialist, said his practice at St. Luke’s Cataract and Laser Institute is one of the largest in the country, which accounts for his numbers. St. Luke’s operates five offices in the Tampa Bay area.

LiVecchi, who has had an eyelid lift himself, disputes that patients are flocking to the procedure primarily with vanity in mind. Patients with droopy eyelids often don’t realize how much the droopy skin is narrowing their field of vision, he said. LiVecchi said he jokes with his patients that he doesn’t want them driving in his neighborhood until after the surgery. “It’s safer for society,” he said.

As for the cosmetic boost, LiVecchi compared eyelid surgery to removing a cancerous lump from a patient’s face. In both cases the doctor’s primary objective is keep a patient healthy, he said. A more youthful appearance is only a pleasant side-effect, which he sees no problem with. “Doesn’t everybody want to look good?” he asked.

LiVecchi said he believes most Americans should have the surgery by the time they are in their late 70s, yet only a small percentage are currently getting the fix. Droopy eyelids, like cataracts, are a fact of life, he said. “It’s something you can’t prevent. It’s part of the aging process.”

Yet 2008 claims records shows that more than 25 percent of eyelid surgeries billed for traditional Medicare beneficiaries were for patients 65 to 69-years-old.

The benefits of functional eyelid surgery for some patients are documented. A 2011 study published in the journal Ophthalmology, for example, found that the surgery provided “significant improvement in vision, peripheral vision, and quality of life activities.”

The surgery does not always go well, and some patients are left worse off. Gail Wilensky, a former Medicare administrator whose husband is a plastic surgeon, said her mother needed the surgery, yet she feels it was poorly performed and left her with tearing for the rest of her life.

Plastic surgeons interviewed said vision problems are not always the draw. Migliori, the president of the American Society of Ophthalmic Plastic and Reconstructive Surgery, said he sees three or four people a day who need the surgery at his practice at Rhode Island Hospital. But he conceded he faces a lot of pressure from patients who do not qualify. “They come in begging for you to do this surgery,” Migliori said. “You get a lot of pressure to bend the rules.”

Migliori said fudging the paperwork wouldn’t be hard. “You could tell the patient to squint,” he said, regarding the requirement that the condition be documented by a photograph, and then fake the vision test. But he thinks the majority of his colleagues are honest.

“To me it seems like a lot of work for something that doesn’t pay that great,” he said.

Surgeons make Medicare eyelid lifts big business

Medicare pays a third, or less, of what many surgeons charge patients out of pocket for cosmetic eye surgery. In the medical world, it is far from a big ticket item. But for practices with a large number of Medicare patients, the dollars quickly add up.

Sean Blaydon, an ophthalmic plastic surgeon at the Center for Aesthetic and Reconstructive Eyelid and Orbital Surgery in Austin, Texas, said his practice is a top biller of Medicare eyelid lifts because with five eyelid specialists, it is likely the largest center in the country. “Our bread and butter is eyelids,” Blaydon said.

Blaydon said the doctors at the Austin clinic drive, and sometimes fly, across central Texas to examine prospective patients referred to them. Candidates travel for the procedure to the doctor’s Austin outpatient surgical center, which is in the same building as the center’s Italian-themed spa that advertises “the Bellisimo Experience,” and offers Botox, skin peels and a variety of cosmetic skin rejuvenation treatments.

Blaydon said the clinic’s high numbers make it vulnerable to Medicare appeals. The center keeps all patient records on site and hands them over to Medicare when they ask for them, he said.

Although Medicare contractors have strict rules for eyelid surgery, Blaydon said it’s hard to judge the reasons why patients are flocking to the surgery like never before. Some of it has to do with vision, he said. And some of it has to do with vanity.

“There is no questioning that when they come here they also want to look better,” Blaydon said.