21st Century Oncology and South Florida Radiation Oncology: The Gamma-Function Billing Case

In the 21st Century Oncology Gamma function settlement, the company agreed to pay $34,695,243 to resolve allegations that it billed Medicare, TRICARE and other federal health care programs for radiation exit-dose procedures that served no medically appropriate purpose. A former physicist at South Florida Radiation Oncology brought the whistleblower case. For someone who knows the equipment, the results or the billing, the alleged disconnect is stark: a procedure could generate a charge even when it produced nothing a physician could use.

The Justice Department’s March 8, 2016 announcement described a provider headquartered in Fort Myers with offices in 16 states. The lawsuit named both 21st Century Oncology and South Florida Radiation Oncology, and the settlement required 21st Century to pay the United States.

An assistant United States attorney in the Middle District of Florida handled the matter. The Justice Department’s Civil Division, the Department of Health and Human Services Office of Inspector General and the Defense Criminal Investigative Service assisted.

The company had already paid $19.75 million in a separate settlement over allegedly unnecessary urine FISH tests and physician bonuses tied partly to laboratory referrals. The Justice Department announced that resolution in December 2015. It concerned the orders sent to the company’s laboratory, while the Gamma allegations concerned the purpose, production and use of radiation measurements.

What the Gamma Function Was Supposed to Measure

The Gamma function measured the exit dose radiating from a patient after radiation treatment. The case brought radiation-oncology billing down to a very practical question: what did the measurement produce, and who used it?

The government’s allegations followed the work from the procedure’s purpose through the equipment’s output to the physician’s review. A physicist could know whether the machine produced a result. A physician could know when that result reached them and whether they knew how to interpret it.

Four Alleged Failures Behind the Gamma Charges

The government alleged that the defendants knowingly billed for Gamma procedures under circumstances that gave them no medically appropriate purpose. Its account identified failures at different points in the work:

1. No medically appropriate purpose. The government challenged why the procedure was being performed and billed in the first place.

1. Staff without the training to use the results. The government alleged that physicians and physicists at 21st Century Oncology locations performed the procedure without proper training to interpret and use its results.

1. Physician review after treatment ended. The government alleged that the defendants billed when no physician reviewed the results until seven or more days after the patient’s last day of radiation therapy.

1. No result from failed equipment. The government also alleged billing when technical failures in the imaging equipment left no Gamma result available.

We see the absurdity most clearly in that last allegation: the equipment failed to produce the measurement, but the procedure still produced a bill. Taxpayers were being asked to pay for a result that, according to the government, did not exist.

The Settlement and the Physicist’s Reward

The former physicist brought the case under the False Claims Act’s qui tam provisions. The announcement said the whistleblower would receive more than $7 million from that recovery.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. That share of the recovery gives someone who knows how a practice’s charges were generated a financial stake in bringing the case.

What Evidence Does a Whistleblower Need?

Gamma charges, treatment dates, equipment output, training records and physician review histories are the evidence we would connect with you. Each alleged failure points to a different part of that account: why the procedure was ordered, whether it produced anything, who could interpret it and when someone did. The person who understands the work can explain what the entries mean.

In ordinary practice billing, CMS’s documentation guidance calls for records supporting actual work, medical necessity and signatures, with the author and original entry identifiable. For an exit-dose charge, that brings us back to the original output and review history. A later signature cannot make a failed measurement produce a result.

The Journal of AHIMA’s 2017 article, Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse, recommends comparing the treatment date, type of treatment and clinical signature in the patient’s record. It also emphasizes witnesses who can explain what happened. That is especially useful in a case where a billing entry and a technical result tell different stories.

Someone in physics may know why the equipment left no result, while someone in billing may know why the charge went forward. We work with you to connect that knowledge to the treatment and billing records and to the decisions behind them. Internal instructions and the response to concerns can explain how an individual charge fits the practice’s way of doing business.

When Work Is Billed but Its Results Go Unused

The Gamma case has a close parallel in Radiotherapy Clinics of Georgia, where the Justice Department alleged excess or unnecessary port films, simulations, physics consultations and pre-plans. Some pre-plans allegedly went entirely unreviewed by the doctor. The whistleblower’s complaint alleged that the practice had explained why it kept preparing them:

The complaint alleged that the practice prepared the plans, billed Medicare and then ignored them. The Gamma case adds the separate questions of whether a result existed, whether staff were trained to use it and whether review arrived only after treatment ended.

Melbourne Internal Medicine Associates and its cancer center’s medical director separately settled allegations of unnecessary or unperformed radiation services billed to Medicare and TRICARE. That case also included alleged executive knowledge without corrective action. Across these cases, the insider’s value is knowing where the service described on the bill parted company with the work inside the practice.

The Result You Know Was Missing

If you saw radiation procedures billed despite failed equipment, unusable results or review after treatment, speak with our Whistleblower Experts about the results that were missing or unusable. We work with you to build your strongest case and bring in healthcare whistleblower lawyers who understand radiation billing and medical necessity. You have a partner from the first conversation through the pursuit of the recovery.