DOJ and CMS Investigate Large Oncology Provider for Fraud.

The Department of Justice (DOJ), the Centers for Medicare and Medicaid Services (CMS) and several additional federal agencies have recently interviewed a CCS Oncology employee as part of their investigation into potential billing irregularities. A local Buffalo news outfit reported that the large and prominent New York based cancer care provider is under federal investigation for possibly defrauding taxpayers out of millions of dollars a year.  In addition, a whistleblower filed a qui tam lawsuit under the False Claims Act alleging that CCS physicians and other staff were involved in upcoding and billing for unnecessary procedures.  The lawsuit alleges that the fraudulent and inappropriate activity resulted in claims costing between $10 million and $15 million per year.  The complaint, dated for July, is filed under seal in the U.S. District Court in Buffalo.

The federal CCS Oncology investigation underscores the DOJ and the Department of Health and Human Services (HHS) Office of Inspector General’s (OIG) continuing focus on oncology services as a high-risk enforcement priority.  Past oncology cases reveal several key factors that have led to settlements with these two federal agencies.  As with the CCS Oncology qui tam lawsuit, most cases of oncology billing irregularities are brought by a “whistleblower”.  Given these agency enforcement and whistleblower risks, Compliance Officers whose portfolio of responsibilities includes oncology services should ensure that their organization is complying with federal and state laws and regulations.

Common oncology enforcement issues include the following:

1. Employees knowingly submit false records to Medicare and Medicaid to increase revenues;
2. Employees submit claims for services performed without the required physician supervision;
3. Providers offer unnecessary treatments and services to patients;
4. The entity recruits and treats patients instead of referring them to hospice care;
5. Patients are given re-treatment in excess of prescribed dosage limits;
6. Employees submit claims for services provided without physician review;
7. Employees submit claims for services where treatment occurred without the required prior IGRT scan;
8. Physicians allow registered nurses to fill out prescriptions for medications;
9. The entity offers inducements (“kickbacks”) to patients by waiving their co-pays;
10. Physicians are conducting unnecessary fluorescence in situ hybridization (“FISH”) tests for bladder cancer;
11. Employees file claims for GAMMA function procedures performed by improperly trained physicians and staff;
12. The organization seeks payments for tests, the results of which were not reviewed by physicians;
13. E&M services are billed on the same day as a related procedure;
14. The entity double and over-bills Medicare for services that lacked supporting documentation;
15. Employees improperly bill for radiation treatment administered without proper physician supervision;
16. The organization submits false claims for magnetic resonance imaging (MRI) services;
17. Employees bill for services that were not documented in the patients’ medical records;
18. The entity bills twice for the same services;
19. Employees misrepresent the level of a service provided to increase their reimbursement;
20. The entity submits claims for services that are not performed, medically unnecessary, and/or are improperly documented;
21. The entity submits claims for services rendered to patients referred by physicians benefiting from the referral;
22. The oncology practice purchases cancer treatments from unlicensed sources;
23. Caregivers dilute patients’ chemotherapy treatments to extend period of treatment time;
24. The entity submits claims for medically unnecessary or improperly documented IMRT;
25. The entity submits unsupported add-on claims for “special treatment procedures” and “specialty physics consults”; and
26. The entity violates the Stark Laws and Anti-Kickback Statute by rewarding referring physicians.