Nearly 20% of Medicare radiation therapy planning payments were improper, OIG says

The CMS doled out nearly 25% more in Medicare payments for certain planning treatments for a common cancer radiation therapy than were warranted, according to a watchdog report released Monday. But the CMS claimed the mistake was due to provider confusion over the agency's guidance.

On top of the $109 million in bundled payments for the treatments, nearly 1,200 hospitals billed Medicare nearly $25 million more for services that should have been included in the bundles. HHS' Office of Inspector General flagged the overbilling in an audit of calendar years 2013 through 2015, but estimates it could have improperly paid out more than $5 million in extra reimbursements in 2016 and 2017.

As a result, the CMS plans to alter the way it edits its claims processing for what's known as intensity modulated radiation therapy (IMRT) planning services. Breast, lung, brain, prostate, head and neck cancers are often treated through IMRT because of the tumors' proximity to critical organs and tissues.

The planning phase of IMRT involves imaging, calculations and simulations that physicians use to plan out the actual radiation. Most of the excess billing—about 84%, according to the OIG —was for complex imaging simulations.

But all of IMRT planning services fall under Medicare bundled payments. The CMS' current editing system didn't catch the hospitals' billing because the treatment for which providers ended up billing separately didn't happen on the same date as the procedure code for the bundled payment. Providers apparently misunderstood the CMS guidance that all complex circumstances around IMRT planning needed to be included in the bundle.

The agency watchdog said hospitals may have been overbilling for other aspects of IMRT planning treatment as well, flagging another $4.2 million in improper payments that could bring the total to nearly $26 million for the audit period.