Melbourne Internal Medicine Associates: Radiation Claims and the Review That Came Later

In the Melbourne Internal Medicine settlement, the practice and its cancer center’s medical director agreed to pay $12 million to resolve allegations of false radiation oncology claims to Medicare and TRICARE. A former director of radiation oncology brought the whistleblower case, with allegations reaching from the treatment room to executives who allegedly knew about the billing. The complaint described a workflow that someone inside the center would recognize: treatment proceeded, and the physician reviewed the images afterward.

Melbourne Internal Medicine Associates provided health care through a network of facilities in Brevard County, Florida. The medical director of its MIMA Cancer Center in Melbourne also practiced there as a radiation oncologist. The Justice Department’s March 23, 2010 announcement described allegations covering the cancer center’s inception through 2008.

The settlement grew out of a coordinated effort by the Justice Department’s Civil Division and the U.S. Attorney’s Office for the Middle District of Florida. The announcement also credits the Department of Health and Human Services’ Office of Inspector General, including its Office of Investigations and Office of Counsel to the Inspector General, along with the TRICARE Management Activity Office of Program Integrity and Office of General Counsel.

What Are Some Examples of Fraud in Medical Practice?

The government’s allegations against MIMA covered unsupervised services, duplicate services, unnecessary services, services never rendered and upcoding. The Justice Department described the upcoding as billing higher procedure codes than the services actually performed. It also alleged that executives knew about a substantial number of the billing practices and failed to stop them.

The whistleblower’s complaint gives those broad categories a place inside the radiation department. It describes therapists taking images and proceeding with treatment, physicians reviewing images later, and additional charges applied routinely across patients.

Image-Guided Radiation Treatment Before Physician Review

The complaint alleged that MIMA billed for image-guided radiation treatment without the physician involvement the service required. It said that after code 77421 was adopted in 2006, physicians were almost never in the treatment room during these procedures. Radiation therapists allegedly performed the work without real-time involvement from the radiation oncologist.

In an earlier workflow described in the complaint, the therapist took stereoscopic x-ray images, stamped them as reviewed and proceeded with radiation treatment. The physician allegedly reviewed and signed the images at the end of the day or later. According to that account, the signature recorded a later review, while the stamp appeared before treatment.

The complaint also described a computer response that told therapists to proceed. Its allegation puts the supposedly immediate review in the machine’s own words:

An automatic acknowledgment was allegedly doing the work of approval. We see an automatic go-ahead dressed up as physician review. Someone who worked at that console could explain what the reply meant in practice and when the doctor actually became involved.

IMRT and the Patient Missing From the Necessity Note

The complaint alleged that MIMA used a preprinted intensity modulated radiotherapy necessity note that gave general information about IMRT instead of explaining the particular patient’s condition. It estimated that Medicare had paid MIMA more than $8 million for medically unnecessary IMRT procedures since the cancer center opened.

That is a concrete medical necessity allegation: the chart contained an explanation of the treatment, but allegedly lacked the patient’s reason for receiving it. A billing employee might see a completed form while a clinician knew that the form supplied the same general explanation from one chart to the next.

Routine Charges Under Codes 77470 and 77370

The whistleblower alleged that MIMA routinely billed code 77470 for nearly every radiation patient. The complaint also alleged that MIMA billed code 77370 for all or nearly all IMRT patients regardless of whether they needed a special physics consultation. One chart comment quoted in the complaint identified an especially plain mismatch: IMRT appeared as the reason for the additional charge even though the patient had not received IMRT.

The chart comment said:

What MIMA Executives Allegedly Knew

The Justice Department alleged that MIMA executives knew about a substantial number of the improper billing practices and failed to stop them. The whistleblower’s complaint also alleged that, after the whistleblower presented concerns, management instructed the whistleblower not to raise them again.

That allegation brings the decision above the treatment room. The therapist’s account concerns when treatment proceeded, the chart concerns what supported the claim, and the management account concerns what happened when the billing concerns reached someone with authority. We look at those connections together because a practice’s response can explain why the same disputed charges kept appearing.

What Evidence Does a Whistleblower Need?

For radiation billing allegations like these, useful evidence connects the claim to the treatment and the people responsible for it. We examine the service date, staff schedule, images, treatment record, signatures and physician-review timing alongside the billed service. The patient’s necessity note, the physics work and communications about billing can explain different parts of the same claim.

In a radiation department, the person performing the technical work and the physician reviewing it may leave different records. A therapist can explain what happened at the console, a physicist can explain the consultation, and a billing employee can explain how the work became a charge. We assess those accounts against the payment requirements that applied on the service date.

The 2017 Journal of AHIMA article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse describes checking treatment dates, treatment types and signatures against the health record. It then explains why the people behind those records matter:

That distinction matters here because a signed image and an automatic reply each tell only part of the story. An insider’s account can establish the sequence: what the therapist saw, what authorized treatment and when the physician reviewed the image. The records become more useful when someone can explain how the department actually worked.

Other Radiation Cases Turned on Need and Review

Radiotherapy Clinics of Georgia agreed to a $3.8 million settlement announced in 2012 over allegations involving excess or unnecessary port films, radiation simulations, physics consults and pre-plans. The Justice Department’s account included pre-plans allegedly never reviewed by the doctor. The clinical use of the work was part of the billing allegation, just as the timing of review was part of the MIMA complaint.

In a separate 2016 case, 21st Century Oncology agreed to pay $34,695,243 over gamma-function radiation exit-dose procedures. The government alleged that procedures lacked a medically appropriate purpose, were interpreted by inadequately trained staff, were reviewed only after treatment ended or produced no result because of equipment failure.

Across these allegations, a billed technical service raises questions about its purpose, its output and who used that output in treating the patient. Radiation staff see those distinctions in daily work. Their knowledge can connect a charge that looks complete on paper to the clinical work behind it.

How Much of a Settlement Does a Whistleblower Get?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In the MIMA case, the Justice Department announced that the former director of radiation oncology would receive a $2.64 million whistleblower reward from the settlement. The former director’s knowledge of how the treatment department worked, and of how concerns reached management, gave the case its view inside the operation behind the Medicare and TRICARE claims.

You Know When the Review Happened

If you know how radiation claims were generated, who reviewed the work or what management was told, speak to our whistleblower experts about the billing you saw. We connect your knowledge of the treatment workflow to the government payments and bring in healthcare fraud whistleblower lawyers who understand radiation billing. We stay beside you as your account becomes a case, from the first conversation through the pursuit of a recovery.