Ophthalmologist Disputes Allegations of Overbilling Despite $20+ Million in Medicare Reimbursements By Tod Aronovitz | 04/15/14 | 0 Comment

Although a well-known South Florida ophthalmologist was paid over $20 million in Medicare reimbursements in 2012—the highest amount of any doctor paid by Medicare that year—the eye doctor has denied wrongdoing and has continually appealed court decisions to make his case.

As we first reported on our ARONOVITZ LAW blog in February 2013, “Florida Eye Doctor under Investigation for Medicare Fraud,” Dr. Salomon Melgen has been the subject of a federal criminal investigation for overbilling Medicare through his use of Lucentis, a drug that treats macular degeneration with a cost of $2,000 per vial.

An analysis of newly-released federal data shows the amount of Medicare reimbursements each provider received in 2012, according to a story in the Wall Street Journal on April 9, “Medicare Paid One Doctor More Than $20 Million in 2012.”

The WSJ article said that the FBI searched Dr. Melgen’s clinics twice last year.  Seventy percent of his practice, which encompasses four offices and employees 30 personnel, stems from Medicare beneficiaries.

A Medicare contractor first accused Dr. Melgen of $9 million in Medicare overpayments in 2009.  Although this charge has been upheld through the courts and an appeals panel within the Department of Health and Human Services last June, Dr. Melgen continued to take it a step further.

Citing a technicality on how the macular degeneration medicine is administered, Dr. Melgen sued the agency in federal court in Miami last August.  He asked that the panel’s decision be reversed and for the government’s recovered money for his alleged overbilling to be returned to him as a result.

That technicality involves how Medicare classifies reimbursements for Lucentis.  The program will pay doctors each time they administer the drug, and the payment is supposed to wrap in the cost of the medication.  However, doctors can take out more than one dose in a single vial to save on drug costs.

The latest court action occurred in October when a filing showed that the Medicare agency agreed to end its payment suspension to Dr. Melgen.  In addition, Dr. Melgen agreed to stop using the controversial dosing procedure to bill Medicare, according to court documents.

Separately at issue is Dr. Melgen’s relationship with New Jersey Senator Robert Menendez.  The senator received donations from the ophthalmologist; paid for two of Dr. Melgen’s trips to the Dominican Republic without first reporting them on appropriate disclosure forms; and pushed the Centers for Medicare and Medicaid Services to clarify its rules after the physician became caught up in the billing discrepancy with the agency.  The Senate Ethics Committee and FBI are conducting ongoing probes, but no charges have been filed.

In a related WSJ article, “Small Slice of Doctors Account for Big Chunk of Medicare Costs,” the new data made public by the Centers for Medicare and Medicaid Services, reveal that the top 1% of medical providers accounted for 14% of Medicare billings in 2012.

How to Report Miami Medicare Fraud

Healthcare professionals 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 Miami whistleblowers to document Medicare fraud and other forms of fraud against the government. Contact Miami Whistleblower / Qui Tam lawyer Tod Aronovitz to discuss a case.