- A report by the HHS Office of the Inspector General said a Medicare contractor, National Government Services, Inc. (NGS), overpaid hospitals for a type of advanced radiation procedure.
- OIG said its review identified 25,900 claims paid by NGS that contained potentially unallowable intensity-modulated radiation therapy (IMRT) services totaling $80.1 million.
- Results of an audit showed overpayments for at least one service for 99 out of 100 beneficiaries in a random sample. Hospitals in two jurisdictions covering 10 states received Medicare overpayments totaling at least $5.7 million for IMRT during the July 2013 through December 2015 audit period.
CMS works with Medicare administrative contractors such as NGS to prevent fraud, process and pay claims submitted for services, and conduct reviews and audits.
IMRT is an advanced radiation procedure for treating difficult-to-reach tumors. Medicare makes a bundled payment to hospitals to cover services involved in developing an IMRT treatment plan. OIG said it conducted its audit because past reviews had found that some hospitals received separate payments for individual IMRT services that should have been included in the bundled payment.
OIG said the overpayments happened because system edits did not adequately prevent payments by NGS to hospitals for incorrectly billed IMRT services. Second, hospitals were unfamiliar with, or misinterpreted, Medicare's guidance when billing for IMRT services, or they cited clerical errors.
In the audit, OIG found that for 95 beneficiaries, hospitals received separate reimbursement for individual IMRT services that should have been included in the hospitals' bundled payment for IMRT. For 46 beneficiaries, hospitals received reimbursement for services not supported by the medical record. One beneficiary received a payment for IMRT services that were not medically necessary.
To recover the overpayments, OIG said it recommended procedural changes to implement payment edits and education of hospitals on how to properly bill for IMRT services. OIG said NGS should notify hospitals to review all services identified in the audit and return identified overpayments.
NGS agreed with the procedural recommendations and said it would take corrective actions, OIG reported. Namely, NGS committed to work with CMS and other contractors to address IMRT payment issues through edits and to provide outreach and education materials to providers. However, the contractor took issue with OIG's characterization of its role as a Medicare administrative contractor and said it was not responsible for implementing and maintaining system edits. It also said that IMRT overpayment recovery is the responsibility of other CMS contractors.
While OIG said NGS did incorrectly pay certain claims, the watchdog also acknowledged that Medicare contractors are not solely responsible for identifying and preventing overpayments.