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Over-billing: just FL culture?

By Cynthia Washam
2/16/2010 © Health News Florida

Brevard County’s largest medical group and the U.S. Justice Department are close to settling the investigation of a complaint that the group’s cancer center overbilled Medicare by more than $8 million, attorneys for both sides say.

The whistleblower complaint said Melbourne Internal Medicine Associates (MIMA) used a super-expensive radiation treatment not only in cases where it was appropriate, but also on hundreds of patients who could have done fine with traditional therapy.

It was the medical equivalent of giving every patient a Hummer when for most, a Ford would do – and then sending the bill for all those Hummers to the taxpayers. In this case, the Hummer was “intensity-modulated radiation therapy” (IMRT), which uses computer-controlled linear accelerators to deliver precise radiation doses to a tumor in a 3-D pattern.

IMRT “wouldn’t harm patients, but you don’t need it” in most cases, said Dr. Eleanor Harris, clinical director for radiation oncology at Moffitt Cancer Center, which also uses it. Examples of tumors that don’t benefit, she said, include breast and lung. 

The MIMA case illustrates the hyper-aggressive treatment style in Florida that researchers at Dartmouth University and elsewhere have noted in national studies of Medicare per-person spending. Medicare beneficiaries in some parts of Florida – especially the southern counties – tend to incur spending that’s far above the national average.

The investigation of the cancer center by the Office of the Inspector General of Medicare’s parent agency, the U.S. Department of Health and Human Services, began after a former MIMA employee filed a whistleblower complaint about the high rate of IMRT.

The legal complaint, filed in October 2009, was to be sealed until the case was settled or tried in court, the customary practice in whistleblower cases. But the judge opened the documents to the public in January, after someone anonymously posted details of the case on the wall at Holmes Regional Medical Center.

The MIMA case bears little resemblance to a recent slew of Medicare fraud cases from South Florida, in which taxpayers were billed for treatments and services that were never given at all or, if given, were outdated and pointless. The accused in those cases are serving time or facing criminal penalties.

By contrast, MIMA is a formidable presence in Brevard, a 41-year-old multi-specialty group with 120 physicians in 18 sites. It won accolades from Imaging Technology News in September 2008 for innovation because of its emphasis on high-tech treatments.

By forming partnerships with medical equipment manufacturers, the IT publication said, MIMA kept its cancer center “at the forefront of technology.” At the time of the publication, the center had three linear accelerators operating and a fourth planned. 

Today, though, there are two linear accelerators in operation, center officials say. The third has been dismantled.

MIMA opened its cancer center in 2003, appointing Dr. Todd Scarbrough as medical director and Fred Fangman as chief radiation therapist. Scarbrough had been a radiation oncologist since 1998, and with the exception of one citation for falling behind on education credits, had a spotless record.

But a year after the cancer center opened, its billing practices were questioned by its auditor, Georgia-based American Medical Accounting and Consulting. The accounting company’s vice president, James Hugh III, said he warned MIMA administrators to stop billing for unnecessary IMRT treatments.

Hugh’s firm audited MIMA again the next year and this time issued a sterner warning. Nationally, Hugh pointed out, IMRT was given to 15 to 25 percent of radiation-therapy patients, while at MIMA Cancer Center, it was about 80 percent.

Hugh told Health News Florida that he found that rate “extremely disturbing.”

When Hugh audited MIMA again in 2007, according to the Justice Department complaint, he warned that the cancer center’s billing practices could get them in trouble with Medicare. He was surprised that MIMA officials kept ignoring his advice.

“My clients, which are about 1,000 cancer centers, normally change the way they do things and go according to that year’s guidelines,” he said.

Scarbrough’s attorney, David Evans of Orlando, contends his client never intended to defraud the government. He said Scarbrough was convinced his patients needed IMRT even if it went against guidelines from Medicare, the American Society for Therapeutic Radiation and Oncology and the American College of Radiology.

“Dr. Scarbrough’s view is that his patients deserve the best technology available,” Evans said. “Radiation oncology has such rapid development and change that if you wait for the government to issue new guidelines, you might be behind the curve.”

Hugh suggests another motive.

“Radiation-oncology equipment costs millions of dollars,” he said. “When you look at the amount of money it costs to run these centers, what you get paid by (insurers and government) isn’t all that much.”

When he realized Scarbrough wasn’t heeding the auditors’ warnings, Fangman took his concerns to Dr. Joseph McClure, MIMA medical director and chairman of the board. Soon afterward, Fangman reported, his new boss threatened he’d be fired if he spoke out again. That’s when Fangman started talking to government inspectors.

Neither Fangman nor Scarbrough could be reached for comment. Evans wouldn’t say exactly where Scarbrough is headed once the suit is settled, only that it’s in the Southeast. “He’s a fine practitioner," Evans said.

--Cynthia Washam, an independent journalist in Jensen Beach, can be contacted via e-mail.