Miami Herald - August 27, 2006
John Dorschner, jdorschner@MiamiHerald.com

"This whole thing is absolutely ridiculous," she said after receiving a notice that Medicare had paid more than $24,000 to a Doral clinic she had never gone to for expensive infusion therapies.

Like many seniors, she knows Medicare fraud is a long-festering problem because she's made complaints in the past and nothing's been done. Indeed, an FBI official says about $1 billion a year in federal tax dollars is lost in healthcare fraud in South Florida alone.

The U.S. Attorney's office in Miami has increased healthcare fraud prosecutions, and Medicare insists it's doing more to stop tax dollars flowing into the hands of crooks -- boasting it stopped more than $2 billion in bad claims in one year just on infusion therapies in Florida.

"The system works, given the limited resources," says Jean Stone, a Medicare official who has investigated fraud in South Florida.

Still, a huge number of phony claims get paid -- and seniors like Sherman gripe that no one seems to care. Sherman started phoning the Medicare fraud line after she received reports from Medicare and her secondary insurance, United American, that Group Service and Associates in Doral claimed she had been visiting its clinic three times a week for three months to receive expensive injections.

NO ONE DOES ANYTHING

Knowing from past experience that calling Medicare didn't seem to produce results, Muriel called the local police and the Federal Bureau of Investigation. When they didn't do anything, she told officers she wanted to visit the clinic herself and confront the staff. Officials warned her not to. She called The Miami Herald and said she was going to the clinic. A reporter told her to leave that to the police.

"The police aren't doing anything. No one is doing anything," she replied. In fact, she had already scouted the place out and learned its hours of operation. "What could happen in broad daylight in a clinic in a shopping center?" She invited the reporter along.

Shortly before noon on a Tuesday, Muriel and her husband, Bill, drove up to the clinic, which occupies a glass storefront in a strip shopping center off Northwest 87th Avenue. Inside was a waiting room with chairs and several certificates on the wall. One indicated the clinic was in compliance with federal privacy statutes. A sign on the door said the clinic's hours were 9 a.m. to 5 p.m. The name of the medical director on the door: Ricardo L. Burgos, MD.

Muriel tried the door. It was locked. She rang a buzzer. A small translucent window -- the kind receptionists open to talk to patients in the waiting room -- appeared to be open a sliver. Sherman thought she might have seen someone peek through the sliver. It was hard to tell. But no one came to the door.

Muriel and Bill stood around, uncertain what to do. A maintenance man came by. He said someone worked in the clinic, but he never saw any patients coming or going. He didn't want to say his name or say anything else.

Muriel sighed. "I feel like I'm doing a mitzvah," she said, meaning a good deed. She vowed to keep going.

When The Miami Herald later called Group Service, no one answered the phone. A letter was left at the office; there was no response. A reporter tried a half-dozen phone numbers for Burgos; all were disconnected or unanswered.

Later, the Shermans went to FBI headquarters in North Miami Beach and demanded to see an agent. Usually, the FBI takes the phone number of the upset senior and that's the end of it. But Sherman pushed hard and said she was talking to The Miami Herald. Two "nice young women agents" then listened to her for an hour.

AIDS TREATMENT BILLS

The agents revealed one tidbit: The billing of expensive infusion drugs -- $500 to $2,000 a shot -- indicated she had been drawn into the most expensive and pervasive Medicare fraud in South Florida -- infusion therapy for persons with HIV/AIDS.

Muriel was insulted. "Can you imagine? I've been married 57 years, and I've only been with one man. And when he had surgery, they tested him, and he doesn't have AIDS."

Infusion therapy -- which doctors say is rarely needed these days as part of HIV/AIDS treatment -- has become a huge business. According to the Governor's Office, Medicare paid out more than $1 billion in 2004 for infusion treatments in Florida -- more than 10 percent of all Medicare claims paid in the state.

The governor's report, contained in a state Senate committee paper last spring, said Florida has far fewer AIDS/HIV cases than California or New York, but providers in Florida submitted charges for AIDS/HIV cases that were more than three times the claims from California and five times more than from New York.

Medicare officials say they are working hard to stem the problem. In 2005, $3.18 billion in infusion therapy was billed in Florida, and only $916 million was paid.

'LIMITED SUCCESS'

The governor's office called this "limited success," because as Medicare computers denied payment on suspect infusion treatments, "the clinics quickly shift dosages and drugs, billing under different codes," according to the senate report.

The clinics also often switch names, owners and locations, closing swiftly as investigators focus on them, only to open under a new name in a different location.

The report was an analysis of a bill to make it easier to shut down suspect clinics, but the move was opposed by providers who run clinics, and it died.

In the case of Muriel Sherman, what puzzles -- and infuriates -- her is that Medicare computers paid out $24,000 while rejecting $60,000 in claims from Group Service and Associates.

Methylprednisolone ($1,500 per injection for anti-inflammation) and Alpha 1 proteinase inhibitor ($2,000) were routinely rejected by the computers while sargramostim injections ($500) and lymphocyte immune globulin ($1,500) were paid.

Bill Sherman doesn't understand how that could happen. If the computers detected major problems in the clinic's billing, why not stop all payments to a provider?

Malcolm Sparrow, a professor at Harvard and author of License to Steal: How Fraud Bleeds America's Health Care System, agreed something is fundamentally wrong. "Just common sense questions how this can be." He sees Sherman's case as a classic example of the underlying problem: Medicare's computers tend to look at each individual claim. "There's no high-level monitoring."

REQUIRED TO PAY

Stone, the Medicare investigator, said computers are programmed to detect some suspicious behavior -- patients getting too much care, rare expensive treatments that get overused and so on -- but Medicare is required by law to pay providers promptly unless there's a glaring problem.

Handling a complaint is a complex process, Stone said, in which Medicare needs to be fair to everyone. A Florida senior's gripe goes first to an operator who works for a Medicare subcontractor, and the information then wends its way to First Coast Service Options, a subsidiary of Blue Cross Blue Shield of Florida, which processes almost 100 million Medicare claims a year in the state.

First Coast then sends out a letter of query to the provider and waits for its reply. "We have a 45-day time frame to start our medical review," Stone said. "It's a progression of steps. If First Coast gets only one or two complaints," the review might stop.

Stone won't estimate how long this process might take, but the next step would be for First Coast to send its file to EDS, a subcontractor that gets about $10 million a year to investigate fraud in Florida.

EDS's staff of 60 in Florida then conducts its own investigation, sending the results to the Office of the Inspector General, which decides whether to prosecute. If the decision is yes, the matter is then sent to law enforcement agents, who do their own investigation, which may or may not lead to an arrest.

All of this could conceivably take many months, during which the suspect clinic continues to collect payments -- or close shop and reopen under a new name. EDS is currently handling 602 investigations. Within the past years, it has referred 60 cases to law enforcement, according to Medicare.

"We get over one billion claims a year from a million providers, and we have limited resources to investigate them," Stone said.

Still, operators continue to be brazen in their operations. In May, FBI agents went to court to ask for a restraining order against Obbar Medical Center, which allegedly ripped off Medicare for $1.6 million in five months -- operating out of a clinic one block from FBI's office in North Miami Beach.

"We are currently working several infusion fraud cases," said FBI spokeswoman Judy Orihuela. "We recognize that infusion fraud is extensive. . . . We appreciate the information that Mrs. Sherman has provided to us."

The last claims report Muriel Sherman received from Medicare in June showed the claims from Group Services and Associates were still being paid. Recently, she called the Medicare hot line to see if payments had stopped yet. She hasn't received an answer.

"I'm not satisfied," she said. "And I'm not giving up."

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WHAT TO DO

Each quarter, Medicare recipients receive a Medicare Summary Notice with lists of services and goods that the government has paid for. If you or a relative see anything on your statement that appears to be fraud, you should call 1-800-MEDICARE (1-800-633-4227) or the Medicare Fraud Hotline 1-800-HHS-TIPS (447-8477). You can also call your local law enforcement agency.

ONLINE EXTRAS

Go to MiamiHerald.com and click on Online Extras. You'll find a forum to give your own comments about Medicare fraud and what happened to you. Or you can write a letter to John Dorschner at The Miami Herald, 1 Herald Plaza, Miami FL 33132 and your comment will be posted. Only comments in which the letter writer agrees to have her or his name used will be published.

CHARGES FOR HIV/AIDS CASES

Investigators suspect massive fraud involving certain expensive infusion treatments. Here is data from 2005 that show how widespread these treatments are here.

**Florida

Patients - 94,725

Claims ( in millions) - $1,552

Charges per patient - $16,389

**New York

Patients - 162,466

Claims ( in millions) - $314

Charges per patient - $1,935

**California

Patients - 133,292

Claims ( in millions) - $524

Charges per patient - $3,932

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SOURCE: State Senate Staff Analysis for Bill 2112, April 24, 2006

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Always watch for outdated information. This article first appeared in 2006. This material is designed to support, not replace, the relationship that exists between you and your doctor.

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