Dermatology Healthcare: Superficial Radiation, Higher-Paying Claims

The $4 million Dermatology Healthcare settlement resolved allegations of inadequate supervision, upcoded procedures and overused radiation simulations billed to Medicare and Medicaid. The disputed claims concerned superficial radiation therapy for nonmelanoma skin cancer. A Palm Beach County dermatologist who brought the qui tam case challenged the billing with something more concrete than a disagreement over codes: what the practice’s radiation machines could actually do.

The Justice Department announced the settlement on August 28, 2018. It covered the Tampa, Florida practice, a physician professional association and two individuals together. The government’s allegations concerned services from January 1, 2011, through December 31, 2016.

The settlement resulted from coordination by the U.S. Attorney’s Office for the Middle District of Florida, the Federal Bureau of Investigation, the Health and Human Services Office of Inspector General and the Florida Medicaid Fraud Control Unit. The Inspector General’s integrity-agreement entry for Dermatology Healthcare also identifies claims review under an integrity agreement.

This radiation-oncology billing case reaches across the treatment room and the billing office. Someone who operated the machine, arranged physician coverage or submitted the claims could know a different part of the same transaction.

The Machines Behind the Claims

The whistleblower alleged that the practice used higher-paying radiation codes than its services justified. The complaint’s account of the equipment tied that allegation to what the practice used for office and mobile treatment:

The dermatologist also alleged that an inspection of the office found neither upgraded electrical service nor specialized cooling units, which the complaint said would have been required for a linear accelerator. That observation made the allegation tangible: the physician was comparing the billed work with the equipment and the building needed to perform it. A higher-paying code cannot upgrade a machine.

The complaint described Medicare reimbursement for superficial-treatment code 77401 as approximately $21 per billing session. It also alleged that, in 2013, the practice billed $414,829 under code 77402 and received $233,386.

Medicare’s physician fee schedule recognizes the staff, space, supplies and equipment behind a service as well as the practitioner’s work. In a procedure-upcoding inquiry, the treatment record and the machine’s capabilities help explain whether the billed service describes the work the practice actually supplied.

Physician Supervision in Office and Mobile Care

The government alleged that Dermatology Healthcare failed to adequately supervise superficial radiation therapy. For someone who arranged coverage or worked with the office or mobile machine, we would examine who performed the treatment, where it occurred and how the physician participated. We line those details up against what each claim said happened.

A separate complaint against Melbourne Internal Medicine Associates shows why timing matters. Its whistleblower alleged that radiation therapists proceeded with treatment before physician approval and that physicians reviewed and signed the images at the end of the day or later. The complaint also alleged that automated email replies told therapists to proceed before the physicians had reviewed the images.

In that alleged workflow, a signature could appear in the chart after the treatment it was meant to guide. For an employee who knew when treatment started and when the doctor reviewed the images, the order of events was the evidence. That is the kind of distinction we examine when supervision on a claim differs from what staff saw.

Radiation Simulations and the Work Around Treatment

The Dermatology Healthcare settlement also resolved allegations of overused radiation simulations and upcoded procedures related to superficial radiation therapy. The government challenged both how often the practice billed simulations and the level of the related procedures it billed.

The complaint against Radiotherapy Clinics of Georgia illustrates how planning work can become a separate source of allegedly false Medicare bills. The whistleblower alleged that the practice performed, billed and then ignored pre-plans that its treatment method did not use. Some allegedly came too late even to serve their stated purpose:

We find the alleged sequence revealing: planning the treatment after it has happened. For someone preparing simulations or treatment plans, the useful detail is how the work reached the physician, whether it informed treatment and what charge followed.

What Evidence Does a Whistleblower Need?

For this kind of health care fraud case, we connect the claim to the treatment, equipment and physician involvement. The Dermatology Healthcare complaint supplies a concrete starting point: the machines available, the code used and the payment received. Treatment records, staffing schedules and the timing of review help complete that account.

The 2020 Journal of Forensic and Investigative Accounting article A Forensic Accountant’s Guide to the Most Potent Federal Laws Used Against Healthcare Fraud separates misdescribing the service from falsely saying the conditions for payment were met. Applied here, that distinction explains why we examine what the machine delivered separately from the supervision behind the bill. Both questions lead back to what the practice asked the government to pay for.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. If your knowledge of the treatment or billing explains a mismatch like these, we can help you build your strongest physician-practice whistleblower case.

You Know the Treatment Behind the Bill

If you know the radiation equipment, the coverage schedule or the claims that went out, speak to our whistleblower experts about where the billing diverged from the work. We build the case with you and bring in healthcare fraud whistleblower lawyers who understand physician billing and radiation services. You bring the view from inside the practice; we bring the judgment and partnership to pursue it with you.