Medicare overpaid millions for radiation therapy planning services, OIG says

Hospitals received up to $25.8 million in inappropriate Medicare reimbursement for outpatient intensity-modulated radiation therapy planning services, according to a report from HHS' Office of Inspector General.

Hospitals failed to comply with Medicare billing requirements for 100 line items audited by the OIG for calendar years 2013-15. Specifically, hospitals separately billed for complex simulations that took place during IMRT planning, which resulted in overpayments, the office said.

The OIG primarily attributed the overpayments to the fact that hospitals appeared unfamiliar with or misinterpreted guidance from CMS.

Overall, nearly 1,200 hospitals received $109.2 million in Medicare bundled payment reimbursement for IMRT planning for calendar years 2013-15, and there was $25.8 million in potential overpayments for separately billed planning services, according to the OIG. Of the $25.8 million, $21.5 million was potential overpayments for complex simulations and $4.2 million was potential overpayments for other IMRT planning services that weren't part of its sample, the office said.

The OIG also estimated an additional $3.7 million in potential overpayments for complex simulations and $1.7 million for other IMRT planning services for calendar years 2016 and 2017, the two years after its audit period, resulting in up to $5.4 million in Medicare overpayments.

Based on its findings, the OIG recommended CMS "implement an edit to prevent improper payments for IMRT planning services that are billed before (e.g., up to 14 days before) the procedure code for the bundled payment for IMRT planning is billed." It also recommended the agency "work with the Medicare contractors to educate hospitals on properly billing Medicare for IMRT planning services."

CMS concurred with the OIG's recommendations.


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