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Windfall for 2% of Medicare Doctors! Is it Fraud?

Windfall for 2% of Medicare Doctors! Is it Fraud?

CMS

April 9, 2015

Florida ophthalmologist Salomon Melgen who received $20.8 million from Medicare.

Medicare data giving a breakdown of each physician was paid was just released.  I’m guessing there are at least few doctors and those at CMS (Centers for Medicare & Medicaid Services) that wish the list didn’t come out ever.  Here’s why:

An analysis by The Associated Press found that a tiny group, 344 out of more than 825,000 doctors, received $3 million or more apiece — a threshold that raises eyebrows for the government’s own investigators. Overall, about 2 percent of clinicians accounted for one-fourth of payments.

Deputy administrator Jon Blum said Wednesday that Medicare will now take a closer look at doctors whose payments exceed certain levels.

I remember reading something about the government not so much wanting to prevent crimes before:

The goal here isn’t so much to prevent a financial crime from occurring but to make investigations more productive,” says Mark Hilts, head of the FBI’s BAU-2, the eight-member group that is overseeing the white collar offender project. “There is no one template for what constitutes a serial killer and the same applies to the white collar world. What we try to do is look at things through the lens of the offender. ”

This line of thinking from the government is costing us all too much.  And why would we not want to prevent a crime?  So only when the negative truth was exposed is the government going to look into what could likely turn out to be fraud?  

“We know there is waste in the system, we know there is fraud in the system,” Blum said. “We want the public to help identify spending that doesn’t make sense.”  Really? Mr. Blum’s own agency appears is having trouble finding fraud and he’s now expecting the taxpayers to do his job for him?   If Mr. Blum worked in the private sector, he’d be fired.  Good thing he works for the government, right?

And now the blame game:

In rural Hastings, Neb., ophthalmologist John Welch said the vast majority of the $9.5 million that Medicare paid him went straight from his practice to drug companies, for expensive medications used to treat patients with macular degeneration.

“I’m concerned that people in the community will get the wrong idea of how these billings reflect doctors’ income,” said Welch, who ranked No. 8 in Medicare payments. “Instead of blaming us, they need to have a serious discussion with the drug companies about lowering the cost of these drugs. If they want us to stop taking care of patients, then tell us that — but don’t blame us for costs.”

I was a pharmaceutical and surgical device rep for over 15 years (and in full disclosure have never sold in the ophthalmic market), but what exactly is Dr. John Welch paying for?  Yes, drugs are expensive and the companies are certainly part of the problem (deflection much?), but patients pay for their medication not the doctors,    Perhaps someone should let Jon Blum know that they should know that insured patients usually have pharmacy as part of their benefits; and, the uninsured pay cash (and those are the people who should be blaming the companies for the cost.)

And is there a special provision in the Hippocratic Oath that I wasn’t aware of that allows a doctor to threaten to ‘stop taking care of patients because of the cost of drugs?”

The overall top-paid doctor in 2012 was Florida ophthalmologist Salomon Melgen, who received $20.8 million.

Last year, Melgen was in the news after revelations that Sen. Robert Menendez, D-N.J., had used the doctor’s personal jet for trips to the Dominican Republic. Menendez’s relationship with Melgen prompted Senate Ethics Committee and Justice Department investigations. The senator reimbursed the doctor more than $70,000 for plane trips.

CMS also releases a fee schedule every year and yes every company is aware of it, and the code that pertains to their product and every doctor is aware of it as it pertains to their procedures.

So is anyone else seeing a common thread? Both Dr. John Welch and Dr. Salomon Melgan are opthalmologists.  My guess, and any rep who has ever sold in pharmaceutical or device, would guess that there is one procedure that pays a ridiculous amount which is being exploited. Mr. Blum this is the public helping you do your job, just like you requested.  And there we have our next Case Study!

Read the full story here

CMS Open Payments infographic from 2014

CMS Open Payments Data as it relates to payouts

FILE – This Jan. 31, 2010, file image (at top) released by Miami Dade College shows Dr. Salomon Melgen, posing for a photo at the book signing of “Growing American Roots”, a book by Sen. Robert Menendez, D-N.J., at the college in Miami. Topping Medicare’s list of highest paid physicians from it’s claims database was Florida ophthalmologist Salomon Melgen, whose relationship with Sen. Robert Menendez, D-N.J., made headlines last year after news broke that the lawmaker used the doctor’s personal jet for trips to the Dominican Republic. Medicare paid Melgen $20.8 million. (AP Photo/Miami Dade College, Phil Roche, File)

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