Port St. Lucie Dermatologist Applied Medicare Billing Code for Radiation Treatment Not Used by Many Doctors By Tod Aronovitz | 06/10/14 | 0 Comment

While there is nothing basically wrong about a physician billing for mainly one treatment, a recent Wall Street Journal analysis showed that the Medicare billings of some single-procedure doctors raise red flags, especially with those who operate outside their area of expertise or greatly diverge from standard medical practice.

According to the June 10 article titled “Taxpayers Face Big Tab For Unusual Doctor Billings,” more than 2,300 providers earned $500,000 or more from Medicare in 2012, but some doctors collected more from a single procedure than any other doctor who billed for that procedure, as shown by Medicare billing codes.

The WSJ’s conclusions emerge from 2012 Medicare physician-payment data released for the first time in April, prompted by the newspaper’s legal action to make this information public.

One doctor whose billing practices were noted in the article is Port St. Lucie dermatologist, Dr. Gary L. Marder. According to the WSJ, Dr. Marder received $3.7 million from Medicare, and of that amount, $2.41 million surfaced from one particular radiation treatment. Only two other doctors in the 2012 Medicare billing code data set studied billed for that treatment, and neither came close to charging Medicare as much as Dr. Marder’s practice did.

The question at hand appears to be the type of machinery used to apply radiation treatment and the billing code used for a specialized machine. The billing code used by Dr. Marder corresponds to a higher-voltage radiation treatment machine that requires extra shielding in a controlled environment, similar to radiation-oncology departments in hospitals.

Broken down by the numbers, a lower-voltage machine (like the one pictured on Dr. Marder’s website) would have been reimbursed by Medicare at a rate of about $22 per treatment in 2012. However, Dr. Marder received an average of $154 per treatment by billing under the code for the higher-voltage machine that Dr. Marder said he used (and was not pictured on his website).

In addition, using the more selective code, Dr. Marder billed for the procedure 15,610 times in 2012, and performed the procedure on 94 patients, according to the Medicare data, adding up to 166 treatments per patient, on average.

According to a radiation oncologist in the WSJ article, the maximum number of radiation treatments appropriate per skin-cancer lesion is 35, and a more typical course of treatment would be 20. Several lesions treated at the same time usually get billed for as a single treatment, the oncologist explained.

Dr. Marder responded that his higher billing count per patient could be attributed to the fact that he billed for each lesion separately and treated each lesion about 40 times.

The question about the type of machine used for the billing code is somewhat similar to a whistleblower case that our May 20 ARONOVITZ Blog reported. In that $89.6 million whistleblower case, a radiation therapy technologist alleged in a qui tam complaint that a doctor and his treatment clinics billed Medicare for procedures that were supposedly performed with a certain type of imaging machine, even though the clinics never actually owned such a machine.

How to Report Miami Medicare Fraud

Healthcare professionals or medical billing employees who have knowledge of questionable Medicare billing practices can file a confidential legal claim under the False Claims Act. By acting as a “whistleblower” in what is known as a “qui tam” lawsuit, a private party may collect between 10 to 30 percent of the amount recovered, depending on how the case is prosecuted.

ARONOVITZ LAW: Miami Whistleblower / Qui Tam Law Firm

The Miami Qui Tam law firm of ARONOVITZ LAW routinely works with whistleblowers to document Medicare fraud and other forms of fraud against the government. Contact Miami Whistleblower / Qui Tam lawyer Tod Aronovitz to discuss your case.