The nuances of "incident-to" billing and the alleged lack of physician supervision from 2006 to 2015 at one of its locations is at the heart of a false claims settlement between Valley Tumor Medical Group Oncology and the United States. The case is United States ex rel. Shindler v. Valley Tumor Medical Group, et al., CV 15-2249.
Valley Tumor paid $2,865,693 to the United States and $134,307 to the State of California on April 13, 2017 to resolve allegations in the lawsuit that it submitted fraudulent bills to the Medicare, Medi-Cal and TRICARE programs when it did not have the required supervision at its Ridgecrest location (which is now closed).
The case was filed by a former employee Jared Shindler who is to receive $555,000 from the settlement and the government intervened. Valley Tumor did not admit liability in settling the lawsuit.
This is a case where the services were provided and necessary but the Medicare billing requirement of having a radiation oncologist on premises was not met at one location even if he or she were available by phone or nearby. A typical oncology treatment plan includes five days a week of radiation lasting one to eight weeks. The delivery of radiation is supervised by the radiation oncologist, who verifies and documents the accuracy of treatment delivery and sees the patient every five treatments to evaluate his or her progress, evaluate toxicity and determine whether treatment should continue or be modified, the complaint states.
The radiation itself is administered by a radiation therapist under the supervision of the radiation oncologist. Because radiation oncology is very specialized, CMS (Medicare) requires the physical presence and immediate availability of the radiation oncologist. This is part of Medicare's "incident-to services" billing requirements, a category to which radiotherapy belowns. If the radiation oncologist is not onsite there is a billing issue. Medicare requirements are stricter than those for private insurance.
Posted by Tracy Green, Esq.
Green and Associates, Attorneys at Law