WASHINGTON — They are the $10 million men of Medicare.
In 2012, seven physicians in the country received more than $10 million in reimbursements for services billed to Medicare, according to newly released federal data. They range from ophthalmologists who submitted claims for specialized, high-cost drug treatments to pathologists who billed the program for thousands of clinical tests performed by their labs.
Some built large, successful practices; others face investigations for fraudulent billing. The doctor with the highest reimbursement total is enmeshed in a criminal inquiry involving a U.S. senator.
It's the first time since the 1970s that Medicare, the public insurance program for seniors, has provided claims and payment figures for individual providers. Among the 880,644 health care practitioners who billed Medicare for services in 2012, the average reimbursement for the year was $87,883. Yet more than 2,000 of those providers broke $2 million in Medicare receipts.
Last fall, Congress' Government Accountability Office raised concerns that Medicare providers with exceptionally high reimbursement rates may be defrauding the program or billing it incorrectly. The investigators recommended that Medicare officials mandate automatic claims reviews for providers whose reimbursements exceed a set threshold, but they did not suggest a specific amount.
The U.S. Centers for Medicare and Medicaid Services, the agency that runs the program, is trying to set a reimbursement threshold that accounts for the varying costs that different practitioners incur for providing care, says spokesman Aaron Albright. "Deterring improper payments is a top priority of CMS in order to protect beneficiaries and taxpayers."
A look at the $10 million men:
• Salomon Melgen, an ophthalmologist in West Palm Beach, Fla., was paid nearly $21 million for services to 900 or so patients in 2012. Nearly $12 million was for Lucentis shots, a macular degeneration treatment costing up to $2,000 per dose — though Medicare generally reimburses only a few hundred dollars per shot. Last year, theWashington Post reported that a grand jury is investigating whether Sen. Robert Menendez, D-N.J., intervened in business matters on behalf of Melgen, a major supporter. Also, the Miami Herald reported that Melgen's Medicare billings are being probed by the FBI. He did not respond to USA TODAY's requests for comment.
• Asad Qamar, a cardiologist from Ocala, Fla., was paid more than $18 million for services to about 1,800 patients. Most of that was for coronary bypass and stenting procedures. Last year, Qamar launched a broad letter-writing campaign to federal officials and agencies, including the White House, to complain that his Medicare reimbursements were being held up by an extensive review of his billings to the program, according to reports by Reuters and local news outlets in Florida. Qamar did not respond to messages left with his office seeking comment.
• Michael McGinnis, a pathologist from Wrightstown, N.J., received about $12.5 million in reimbursements for services provided by laboratories that he runs. More than $5 million of that was for a particular type of tissue analysis. As a lab operator, McGinnis' name is attached to billings for analyses conducted by multiple pathologists providing services. McGinnis said the total credited to him involves billings for 28 pathologists, working in the largest independent anatomical pathology lab in the country. And, he added, "I work very hard."
• Franklin Cockerill, a pathologist who chairs the Mayo Clinic's Department of Laboratory Medicine and Pathology in Rochester, Minn., received more than $11 million for laboratory services. As a lab director, Cockerill was listed as the billing physician for tens of thousands of analyses performed by Mayo Clinic personnel, regardless of whether he was involved personally, according to Bryan Anderson, a Mayo spokesman. For example, Cockerill was listed as the billing physician for more than 40,000 creatinine assays, which measure kidney function.
• Alexander Eaton, an ophthalmologist from Fort Myers, Fla., received $10.7 million for services to about 2,700 patients. Nearly $6 million of that was for injections of Lucentis, the high-priced drug for treatment for macular degeneration. Eaton, founder of Retina Health Center, which has two clinics in Southwest Florida, specializes in treating macular degeneration, the leading cause of vision loss in seniors. His office did not respond to requests for comment.
• Vasso Godiali, a vascular surgeon from Bay City, Mich., received $10.1 million for services to about 1,600 patients. Much of the billing was for surgical procedures to remove blood clots or repair arterial blockages. He also was reimbursed for treatments to prevent aneurysms and coronary artery disease. Godiali and his staff did not respond to calls and messages seeking comment.
• Farid Fata, a hematologist and oncologist, received just over $10 million for services to nearly 1,350 patients. Much of that was for chemotherapy infusions. Last year, Fata was arrested in an FBI investigation and charged with health care fraud, paying and receiving kickbacks, money laundering and immigration violations. He allegedly administered chemotherapy to patients misdiagnosed with cancer, patients in remission, and end-of-life patients who would not benefit from treatment. He is in custody awaiting trial, according to the U.S. attorney's office.