The OIG recommends that Novitas reopen claims to recover more than $7 million in IMRT overpayments

Novitas Solutions, Inc. plans to pursue $7.2 million in intensity-modulated radiation therapy (IMRT) overpayments to hospitals in its jurisdiction, according to an Office of Inspector General (OIG) report published November 8.

Medicare generally reimburses hospitals for IMRT services with a bundled payment that covers the range of individual services that are performed as part of an IMRT treatment plan. Past OIG audits found that some hospitals were billing for and being paid for separate IMRT services in addition to the bundled IMRT payment. For this audit, the OIG reviewed IMRT claims data from hospitals in Medicare Administrative Contractor (MAC) Jurisdictions H and L.

The OIG used data analytics to identify IMRT claims at greater risk for overpayment. Out of that pool of 28,776 claims generated from 2013-2015, the agency selected a random sample of 100 beneficiaries and reviewed all claims associated with their treatment. For 98 beneficiaries, Novitas made at least one incorrect payment. Based on the sample results, the OIG estimated that Novitas overpaid hospitals $7.2 million during the audit period.

For 94 beneficiaries, Novitas made separate payments for IMRT services that should not have been billed separately and were included in the hospitals’ bundled payment. For 50 beneficiaries, the medical record did not support the services billed. And for four beneficiaries, the OIG’s independent medical reviewer determined that the services were not medically necessary.

According to the OIG, the errors were due to the following reasons:

• Novitas’ claim processing system did not adequately prevent payments to hospitals for all incorrectly billed IMRT services
• Hospitals were unfamiliar with or misinterpreted Medicare guidance when billing for certain IMRT services or cited clerical errors

The OIG recommended that Novitas:

• Recover a portion of the estimated $7.2 million in overpayments
• Notify hospitals responsible for the remaining estimated overpayment so that those hospitals can identify and return any overpayments
• Identify and recover IMRT overpayments made after the audit period
• Educate hospitals on billing Medicare for IMRT planning services
• Work with CMS to implement edits that would prevent separate payments for services included in the IMRT bundled payment

Novitas either agreed or partially agreed with each the OIG’s recommendations.