Recent Medicare Review Found Huge Percentage of Possible IMRT Fraud
Medicare provides health insurance to Americans age 65 and older and certain others with disabilities. Part B of the Medicare program provides coverage for hospital outpatient services.
Medicare is a government program funded by tax dollars. It uses Medicare Administrative Contractors to process and pay Medicare claims submitted for services, conduct reviews and audits, and safeguard against fraud. These “MACs” are assigned a certain geographical area.
To avoid waste and insure quality care, Medicare has a few basic rules. One is that the program will only pay for services that are medically necessary. Claims must also be supported by proper documentation. The MAC’s job is to make sure hospitals billing properly.
One of the medical services covered by Medicare is Intensity Modulated Radiation Therapy or “IMRT.”
IMRT Intensity Modulated Radiation Therapy
IMRT is a medical procedure that uses computer algorithms to plan and precisely deliver radiation to tumors. The intensity of the radiation can be adjusted to deliver higher
doses to a treatment area while reducing exposure to surrounding healthy tissue.
IMRT is provided in two treatment phases: planning and delivery. The planning phase involves
multistep process involving diagnostic imaging, calculations, and simulations. These are used to develop a treatment plan.
In the delivery phase, photon and proton beams are delivered to a patient’s tumor at the various intensity levels as required by the IMRT treatment plan. The machine delivering the radiation actually shapes the beams to conform to the shape of the tumor.
Bundled Services
A frequent Medicare fraud scheme involves unbundled services. Medicare and Medicaid require many services to be bundled. Let’s look at an easy example. If a patient comes in for an allergy shot, Medicare should be billed once. Some providers, however, will attempt to bill for a separate consultation, office visit, extensive examination and the shot.
In IMRT cases, the planning should all be bundled. In other words, Medicare disallows separate charges for imaging, image review, planning, consultations and the like.
Medicare Audits MAC National Government Services
In December, the Centers for Medicare and Medicaid Services (CMS) released an audit report on IMRT billing. The audit was done on National Government Services which is the MAC for 10 states in the Midwest and Northeast United States.
To conduct the audit, regulators chose a sample of 100 claims over a multi-year period.
The results of the audit were not good. 99 of the 100 sample bills had problems – overpayment problems. According to the findings,
“NGS incorrectly paid hospitals for IMRT services provided to nearly all of the beneficiaries associated with our review. Although most of the IMRT services billed by hospitals were allowable, we determined that NGS made overpayments for at least 1 service for 99 of the 100 beneficiaries in our random sample.”
95 of the bills has services improperly claimed for reimbursement. 46 did not have the proper documentation to support the service and in one case, regulators found the services were not medically necessary. If you do the math, that is 142 major billing problems in just 100 bills. In other words, almost half the bills had multiple billing errors.
Extrapolating the sample to the entire universe of claims in those regions, CMS says they “identified 25,900 claims that contained potentially unallowable IMRT services provided to 16,199 beneficiaries, totaling $80,113,196.”
Potential Whistleblower Claims – Medicare Fraud Cash Rewards
Medicare fraud has reached epidemic levels in the United States. Whether some hospitals were deliberately ignoring the rules or were ignorant of them, taxpayers apparently paid millions more than they should have.
The audit was limited to two regions consisting 10 states and looked at two years of data. Are these same problems happening in the other states? Our educated guess is YES!
National Government Services tried to block the release of the report! They also suggested that they don’t have an obligation to police the hospitals for which they oversee payments. Wrong!
We agree that the hospitals are primarily at fault but the MACs are the interface between the hospitals and Medicare. Their core responsibility is to make sure hospitals properly bill and document their services.
There are no awards to be had with respect to IMRT billing and NGS. The government has already audited the claims and NGS is reluctantly coming to the table according to CMS.
We wonder if National Government Services is missing the boat on other types of claims. And we wonder what is happening in the other 40 states. Both scenarios present new reward opportunities and the opportunity to help save tax dollars.
Under the False Claims Act, whistleblowers with inside information about Medicare and Medicaid fraud (VA medical care too) can receive a reward of between 15% and 30% of whatever the government recovers from the wrongdoers. Our clients have received over $100 million in rewards
Who Are the MACs?
As of December 2018, the following MAC contracts have been awarded.
- Wisconsin Physicians Service Insurance Corporation: Iowa, Kansas, Missouri, and Nebraska (Jurisdiction 5), Indiana and Michigan (Jurisdiction 8)
- CGS Administrators: Kentucky, Ohio (Jurisdiction 15)
- Noridian Healthcare Solutions LLC: American Samoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands (Jurisdiction E), Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming (Jurisdiction F)
- Novitas Solutions Inc: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas (Jurisdiction H), Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania (Jurisdiction L)
- National Government Services: Illinois, Minnesota, and Wisconsin (Jurisdiction 6), Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont (Jurisdiction K)
- Palmetto GBA LLC: Alabama, Georgia, and Tennessee (Jurisdiction J), North Carolina, South Carolina, Virginia, and West Virginia (Jurisdiction M)
- First Coast Service Options, Inc.: Florida, Puerto Rico, and U.S. Virgin Islands (Jurisdiction N)
Do You Have Info about IMRT Billing Fraud? You May Be Entitled to a Reward?
We are currently looking for present or former employees of Wisconsin Physicians Service Insurance Corporation, CGS Administrators, Noridian Healthcare Solutions, Inc, Novitas Solutions, Inc., Palmetto GBA, LLC and First Coast Service Options with information about IMRT billing deficiencies. We are also looking for billing specialists served by these MACs. Finally, we are seeking whistleblowers form National Government Services with information about billing problems not involving IMRT.
To learn more, visit our Medicare fraud whistleblower information page. Ready to see if you qualify? Contact us online, by email at *protected email* or by phone at 414-704-6731 (direct). All inquiries protected by the attorney – client privilege and kept confidential. We accept cases throughout the United States.
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