Medicare fraud

[PLT]

I'm Canadian and haven't really followed some of the previous discussion, but I know there have been some threads about overbilling in the past.

Does this relate?

Georgia-Based Radiation Oncology Practice to Pay $3.8 Million to Settle False Claims Act Case (http://www.justice.gov/opa/pr/2012/April/12-civ-426.html)

I can see how direct overbilling of particular services would be fraud, but what about concerns of using IMRT etc if not "medically neccessary"

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[seper]

I haven't heard of this particular case. As always, any details would be appreciated. I do suspect this may have something to do with multiple IMRT conedowns for prostate Ca.

I've seen people billing 4 IMRT plans per RT course: prostate + SV with 1 cm margin, then conedown to prostate + SV + 0.5 cm, second boost to prostate only + 0.5 cm, and final conedown to prostate only. All IMRT.

 

[medgator]

Typically, they will just reverse charges (or not pay for them) when it comes to using IMRT in a case where the insurer feels it is not medically necessary. You will then have to appeal it.

In the medicare fraud case you alluded to, it was more an issue of frank overbilling (billing special physics consults when unnecessary) or billing for procedures not performed.. This was the case in the MIMA case in FL a few years ago.

http://www.justice.gov/opa/pr/2010/March/10-civ-299.html

 

[deleted4401]

Multiple conedowns isn't fraud. You can only get reimbursed once for the plans... I do it. We are not getting rich off of it. It does make life harder for your planners, though.

 

[medgator]

Multiple conedowns isn't fraud. You can only get reimbursed once for the plans... I do it. We are not getting rich off of it. It does make life harder for your planners, though.

I believe there are some technical charges generated for it, at least a new CT sim (if you re-simming for a boost)

 

[seper]

One might be tempted to do multiple sims+image fusion+checking composite plans using physics consults.
Also, for those who do IMRT conedowns, do you charge for repeat verification sim?

 

[deleted4401]

We don't do a re-sim CT. We can charge all we want, but we don't collect for 2nd v-sim. It's more just because that's how I learned how to do it residency.

 

[radiaterMike]

SimulD- it depends on local insurers. Even CMS has regional variability in how IMRT is reimbursed. What we may eventually see is reimbursement based upon diagnosis and treatment - i.e. fixed amount for radiation for prostate cancer, whether it is treated with IMRT, 3dCRT, proton therapy, +/- IGRT, etc., regardless of number of fractions, number of fields, number of dose calculations, number of plans, etc.

 

[deleted4401]

You guys freaked me out, so I called our biller. We get a flat reimbursement from our insurers, regardless of the number of PTVs - regardless if sequential or simultaneously planned. It's a global fee for that IMRT code. We get paid for the first v-sim, but nothing extra for each additional v-sim for each conedown. If we re-CT'd during the treatment to re-plan, we wouldn't collect anything for the second CT sim, nor do we get anything for the adapted plan. I believe that's how it was at our residency, as well - that's what they had told me, at least.

 

[jcradonc]

More fraud in radonc....

http://www.prnewswire.com/news-rele...fraud-cancer-treatment-lawsuit-300000484.html

 

[medgator]

M
ore fraud in radonc....

http://www.prnewswire.com/news-rele...fraud-cancer-treatment-lawsuit-300000484.html

I knew that name sounded familiar....

http://www.nytimes.com/2004/01/07/nyregion/beatle-s-estate-sues-doctor-over-breach-of-privacy.html

http://cityroom.blogs.nytimes.com/2...guilty-of-malpractice-but-not-wrongful-death/

http://nymag.com/nymetro/health/features/10817/

Sounds like he was doing Lung SBRT and billing it as intra-cranial since a lung code did not exist prior to 2004

http://www.silive.com/news/index.ssf/2008/09/staten_island_university_hospi_3.html

Ferreri said the procedure was performed on lung-cancer patients and billed as brain-cancer treatment. That was done, he said, because there was no billing code for lung-cancer stereotactic radiosurgery. Such a code was created in 2004, he said.

 

[seper]

Oh this guy is a legend in NYC and beyond. Can't believe he is practicing. Look him up re: George Harrison.

 

[radiaterMike]

Agree with you. It is amazing how hard it is to lose your license. I suspect that the fraud was intentional, although a valid counterargument is that perhaps the billing was somewhat justifiable if one didnt understand that those codes were exclusive to CNS lesions. However, deceiving patients and unncessarily treating patients is clearly malpractice. In this day in age (in which people perform internet searches on everyone and anything), not sure how he gets new patients.