Radiotherapy Clinics of Georgia: Pre-Plans Allegedly Prepared After Surgery

Radiotherapy Clinics of Georgia agreed to a $3.8 million settlement over allegations that it overbilled Medicare for port films, radiation simulations, physics consultations and pre-plans. A former employee and a former doctor brought the case from inside the practice. Their allegations reached into the treatment workflow: the government described unnecessary or unreviewed plans, and a whistleblower’s complaint alleged that some pre-plans were prepared after surgery.

The Justice Department announced the settlement on April 3, 2012. The practice, based in Decatur, Georgia, allegedly billed for excessive and medically unnecessary services for prostate-cancer patients.

What the Practice Allegedly Billed

The government’s allegations covered both the amount of work billed and whether particular work was medically necessary or reviewed. The settlement announcement describes the services in terms a radiation-oncology employee would recognize:

• Port films: X-ray images of the treatment area, for which the government alleged Medicare overbilling.
• Radiation simulations: The process of defining, filming and marking treatment fields on the skin in preparation for personalized radiation therapy. The government alleged overbilling for these services too.
• Physics consultations: Complete special consultative reports for an individual patient. These were another category of alleged excess billing.
• Pre-plans: Plans ordered by the physician that the government alleged were medically unnecessary, never reviewed by him, or both.

For an insider, the pre-plan allegation raises a concrete question: where did the work enter the patient’s treatment? The complaint alleged that plans were produced and billed even though the practice’s treatment method did not use them. That puts the clinical use of the output at the center of the medical necessity fraud allegation.

When the Pre-Plan Came After Surgery

The whistleblower’s complaint alleged that the practice performed a pre-plan for every ProstRcision procedure, billed Medicare and then ignored the plan. It described a routine source of income attached to work the treatment method did not use. One short allegation makes the timing problem unmistakable:

A pre-plan for surgery that had already happened. We would call that a bill, not a plan. The allegation gives the plan’s creation date real significance: it can show where the billed work sat in relation to the treatment it supposedly helped prepare.

The complaint also alleged that the defendants repeatedly told the whistleblower the information generated by pre-plans was not used for its intended purpose. According to that account, they considered the plans medically unnecessary but lucrative. Those alleged conversations connect the unused output to what people directing the business knew about it.

Enhanced Plans and Higher Reimbursement

The complaint alleged that the practice began running more enhanced pre-plans using CPT code 77295 for three-dimensional reconstruction. It said those plans allowed greater Medicare reimbursement. The same complaint alleged billing for several hundred patients’ pre-plans, giving the unused-plan allegation a repeated billing pattern rather than a single disputed chart.

That alleged change adds a payment question to the timing question. We work with you to connect the enhanced output to the code billed and ask how the additional planning was actually used for the patient. The useful comparison is between the work produced, its clinical use and the Medicare claim it generated.

The Physics, the Physician and the Billing Trail

A physics employee, a physician and a biller can see different parts of the same claim. In this case, the government attributed the pre-plan orders to the physician, while the complaint described what happened to the output and alleged conversations about its lack of use.

For a physicist familiar with the workflow, the relevant knowledge may be what was produced and when it became available. A physician may know what was ordered, reviewed and used to guide treatment. A billing employee may know how that work became a service code and a Medicare claim. We connect those accounts to the particular patients and services they describe.

What Evidence Does a Whistleblower Need?

A whistleblower needs evidence connecting the billed service to what happened in the practice. We work with you to connect the billing evidence to the plan order, surgery date, physics output and physician review. Your knowledge of how those records were created helps us understand what the Medicare claim leaves out.

The industry’s documentation requirements make the original record important: it must support the work, its medical necessity and who made the entry. A signature can identify the reviewer, while the sequence of orders, work and treatment shows what was available to review. In an unused-plan case, we need both the paperwork and the account of how the practice actually worked.

The 2017 Journal of AHIMA article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse recommends comparing the treatment date, treatment type and clinician signature with the health record. Its next point explains why an insider’s account belongs beside those documents:

Another Radiation Case With Review After Treatment

In a separate case, the whistleblower’s complaint against Melbourne Internal Medicine Associates alleged that radiation therapists proceeded with treatment before receiving physician approval. It described physicians’ computers sending an automatic response:

The complaint also alleged that physicians signed images at the end of the day or later, after treatment had proceeded. It separately alleged that generic preprinted medical-necessity forms supplied information about intensity-modulated radiation therapy without discussing the particular patient’s condition. Special physics consultations were allegedly billed routinely regardless of need.

The comparison is the gap between the claimed service and the sequence inside the clinic. In the Georgia complaint, a plan allegedly went unused or came after surgery. In the Melbourne complaint, treatment allegedly went ahead before physician review, and patient-specific justification gave way to a generic form. An employee who knows when the work happened and how it was used can make that gap visible.

The Whistleblower Case Behind the Settlement

The former employee and former doctor filed separate qui tam complaints. The investigation joined the FBI, the Health and Human Services Office of Inspector General, the U.S. Attorney’s Office for the Northern District of Georgia and the Commercial Litigation Branch of the Justice Department’s Civil Division.

The Justice Department announced a joint whistleblower reward for the two former insiders. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

Your Knowledge of the Plan and the Claim

If you worked in radiation oncology and know which plans were used, which were ignored or how they reached Medicare, speak to one of our Whistleblower Experts about the plans and claims you know. We develop the case with you and bring in health care fraud whistleblower lawyers who understand radiation planning, physician review and billing. You bring the knowledge of the practice, and we stay beside you as partners through the whole process to build your strongest radiation billing whistleblower case.