DALLAS – One doctor served prison time for health care fraud. Another has been disciplined by regulators five times, on charges including dangerous overuse of anesthesia. A third devotes his practice to a controversial therapy that Medicare won't cover.
That didn't stop Medicare from paying them, even though they also billed in extremely unusual ways. They're among 163 Texas caregivers who led the nation in per-patient use of certain procedures, a Dallas Morning News analysis of Medicare data shows.
Such billings don't mean a doctor has done anything wrong or is out of compliance with Medicare rules. But experts say these patterns do indicate potential overtreatment – a form of waste that costs U.S. taxpayers tens of billions of dollars annually.
The News analyzed 2012 payment data released in April by Medicare, the U.S. insurance program for elderly and disabled people. The data allow health care consumers for the first time to see how much their doctors bill Medicare and for what. Government officials said they also hoped the data would help expose misspending.
"We want the public's help," said Jonathan Blum, a senior Medicare administrator. "We want reporters' help to identify spending that doesn't make sense, that appears to be wasteful, that appears to be fraudulent."
Researchers have found that up to 42 percent of Medicare patients experience unnecessary treatment. A 2012 report said Medicare and Medicaid, the government insurance program for the poor, waste up to $87 billion annually on "care rooted in outmoded habits, supply-driven behaviors and ignoring science."
Dr. Donald Berwick, formerly Medicare's top administrator, co-authored that report in The Journal of the American Medical Association. It identified overtreatment as possibly the largest single category of waste in Medicare and Medicaid.
"I don't personally believe the majority of this is ill-intended or intentionally destructive or wrong on the part of doctors," Berwick said in an interview. "A lot of times that has to do with knowledge transfer, and some doctors just lose track of what the science is saying."
Jonathan Skinner, a prominent health care economist, reviewed The News' analysis.
"I think there's overutilization and then there's overutilization. The space you're in is overutilization with a capital 'O,' " said Skinner, a professor at the Dartmouth Institute for Health Policy & Clinical Practice. "This is not normal behavior."
Skinner cautioned, though, that Medicare billing patterns don't tell a complete story.
"It's really hard to back out which physicians are providing low-quality care," he said. "These data are very good at showing doctors who have tapped into the federal treasury, but they don't tell you who's the good or bad doctor."
Medicare paid the 163 Texas caregivers who had extremely unusual billings a total of $81 million in 2012. The News found 21 of them had previously been disciplined by the Texas Medical Board – including several who allegedly endangered their patients or otherwise practiced medicine unsafely. In general, board records show, the doctors admit no wrongdoing.
One of them was Dr. Jonathan Walker, who runs the Neurotherapy Center of Dallas. It advertises drug-free treatment for problems such as seizures, autism, dyslexia and sports-related head injuries.
In 2012, Medicare paid Walker for 1,302 medium-complexity office visits with 60 patients. That rate, 21 visits per patient, was nearly 80 percent higher than the next-leading neurologist in the nation and over 15 times the national average. Walker received about $70,000 for those office visits – the only thing for which he billed Medicare.
Walker said he sees patients much more often than his peers because he provides neurofeedback therapy. It's a controversial form of biofeedback based on the idea that patients, through a long series of training sessions, can learn to control their brain waves and thus their neurological disorders.
A typical training includes 30 minutes of watching a film or playing a video game while electrodes record brain waves. If the electrodes detect what's deemed abnormal activity, the patient gets negative feedback – a fuzzy screen, for example – until brain activity returns to normal. Walker said he follows up by talking with patients "about changes they've noticed associated with the procedure."
Medicare doesn't pay physicians for the kind of biofeedback Walker performs, according to its billing rules. Walker acknowledged that and said he thought it should be a Medicare-covered expense. "We ask them to pay for the follow-up visits in lieu of paying for the training," he told The News.
Office visits must be for medically necessary treatments or exams, the billing rules say. Medicare officials declined to comment on Walker's case or other individual caregivers.
The Texas Medical Board has disciplined Walker twice for using or recommending unconventional practices.
In 1998, the board reprimanded him for "failure to practice medicine in an acceptable manner consistent with public health and welfare." It cited what he called "Eastern healing techniques," which included using his fingertips to "thump" a woman's thyroid, abdomen and groin. He also prescribed black currant oil for her cancer and migraine headaches, records show.
Another patient referenced in the order also came to Walker for migraine treatment. He failed to consult medical records she brought and chose medication "using what he termed the 'Chinese method' of drug selection," the order says. In this method, bottles of medicine were placed in a basket on her abdomen and picked based upon how much resistance she gave to pressure on her arm.
Because the patient wanted traditional treatment, Walker prescribed a conventional drug. It was one to which she had a documented allergy, the order says. There's no mention of whether the woman suffered an adverse reaction.
In 2009, the board fined Walker $1,000 and ordered him to take a medical record-keeping course. It said he failed to document his evaluation of two patients to whom he recommended biofeedback therapy.
In an interview at his North Dallas office, Walker said many patients come to him after they've exhausted a drug regimen prescribed by other doctors. He said that 95 percent of his neurofeedback patients get better.
The 2012 Medicare figures show that Baytown oncologist Kashif Ansari led the nation in two procedures: blood counts and injections per patient of ranitidine hydrochloride, which counteracts chemotherapy-related nausea. He also ranked in the top 1 percent of oncologists nationally for his per-patient use of intravenous chemotherapy.
Medicare paid Ansari about $86,000 for these three types of procedures and more than $513,000 overall in 2012.
Ansari said he has significantly cut back his practice since then and was no longer seeing Medicare patients. He declined to comment on his billing practices during a brief phone interview.
"I'm not into that anymore; I'm more into cricket," he told The News. "I've been watching cricket and doing commentary."
In 2010, the medical board fined Ansari $2,000 and ordered him to be monitored by another doctor for five years. It found that he improperly used chemotherapy with patients between 2005 and 2008. At times, the board said, he failed to properly keep or consult medical records.
In one case cited, Ansari prescribed a chemotherapy treatment that put a patient at risk of congestive heart failure. In another, he gave a patient with Stage II breast cancer a type of chemotherapy designed for Stage IV. That "may have resulted in severe burn side effects," the board said.
Ansari also did not discuss the risks and benefits of a chemotherapy treatment plan with an 85-year-old patient, according to board records. Chemo isn't well-tolerated at advanced ages and, according to researchers, is often used despite providing minimal benefit to elderly patients.
The medical board said Ansari had "rehabilitative potential" and "expressed a very sincere passion aimed at helping cancer patients."
San Antonio anesthesiologist Fernando Avila has been disciplined more often – five times – than any Texas doctor with these unusual Medicare billing practices, according to the newspaper's analysis. Avila, who works at a pain management center, gave more injections per patient of ketorolac tromethamine, an anti-inflammatory drug, than any other anesthesiologist in the nation. His rate, more than 12 injections per Medicare patient, was more than three times the national average, the analysis showed.
The ketorolac tromethamine injections made up a tiny fraction of Avila's total payments from Medicare, just $411 of about $829,000 in 2012. That's because Medicare pays about 25 cents per dose of that medicine. But for the procedure to administer the injections, Medicare pays a lot more. In fact, Medicare paid Avila at least $501,000 for administering almost 4,000 injections of several types of medicine. His largest billing was for epidural injections to treat spine pain, for which he received about $95,000. His per-patient rate for that procedure also put him in the top 1 percent of anesthesiologists nationwide.
The Texas Medical Board has sanctioned Avila for a variety of misconduct, including not releasing medical records, failing to recognize patients' addiction risks and employing a doctor whose license had been revoked because of a fraud conviction. Avila did not let the employee treat patients or handle billing, the board said.
In 2011, Avila was fined $2,000, reprimanded and ordered to enroll in a clinical competency program after administering an anesthesia overdose. The patient quit breathing in Avila's office and suffered brain damage, according to board records.
Avila admitted that his office was not properly registered to administer the type of anesthesia the patient received, the board said. It commended him for taking steps to improve his record keeping and hiring nurses who specialize in anesthesia.
Avila, speaking through an administrator at his practice, declined to comment on either his medical board record or his Medicare billings.
Two Texas doctors identified by The News for unusual Medicare patterns have previously been accused of illegal billing.
One is Greenville-based orthopedic surgeon Jack Thomas. Medicare paid him about $36,000 in 2012 for fluoroscopic needle placement – real-time X-ray imaging to guide injections. His treatment rate, just over six procedures per patient, was the highest in the nation among orthopedic surgeons. The national average was about 1.5.
In a phone interview, Thomas said he used fluoroscopy to help him inject joint lubricants into the knees of patients suffering from osteoarthritis. For joint injections, Thomas' per-patient rate put him in the top 1 percent of orthopedic surgeons nationwide. He said he was well within the allowed limits of Medicare, which paid him about $57,000.
He noted that one organization in California had a per-patient rate slightly higher than his. The News' analysis focused only on individual providers.
Thomas lost his medical license in 1991 after being criminally charged with diverting thousands of doses of narcotics. He also faced fraud charges – because, he said, he billed Medicare for a partner physician who hadn't performed a procedure. Convicted on the charges, Thomas was sentenced to eight years in prison and paroled after less than one.
The medical board gave him back his license in 1999 after experts said he had successfully undergone mental health treatment. Then Medicare took him back, too.
In 2011, the medical board's staff accused Thomas of scheduling a shoulder surgery without properly evaluating the patient. An order resolving the case made no mention of that allegation, but did say the surgeon "failed to document his pre-operative discussion of the risks and benefits" of a knee replacement. The board fined Thomas $2,000 and ordered him to take a course on record keeping.
In total, Thomas received more than $231,000 from Medicare in 2012.
Jaime Lim, the other doctor with the history of illegal billing accusations, received far more that year. A neurologist and pain management specialist in Wichita Falls, he billed at the highest per-patient rate in the nation for two procedures related to back pain injections. That was over twice the national average.
Medicare paid Lim over $95,000 for the procedures and about $852,000 overall.
In 2003, the medical board alleged that Lim "repeatedly provided substandard diagnosis, treatment and documentation for the purposes of unlawfully, deceptively or fraudulently increasing fee revenues." It detailed the cases of seven women he'd treated over the course of a decade. In two cases, he was accused of "wrongfully misreporting normal EEG results."
Lim resolved the case by agreeing to spend three years on probation, with his practice monitored by another doctor. He signed an order stating that he broke the law "by prescribing or administering a drug or treatment that is nontherapeutic."
The order contained no finding of fraud, Lim noted in an interview. It also included no admission of wrongdoing.
In a phone call with The News, Lim said that he had rebuilt his practice and thought it was unfair to mention his past troubles with the medical board. Lim said he was certain that he was not abusing Medicare's rules or overtreating patients. "I will open my practice for any scrutiny," he said.
Some doctors say the recently released Medicare data has been used to paint them in a bad light. Those payments don't always represent the amount of money doctors earn because they may also include reimbursements for overhead costs, such as medicine and supplies.
Ophthalmologists, for example, say their billings are high because they include the costs of expensive drugs for treating macular degeneration.
Sidney Gicheru, president-elect of the Texas Ophthalmological Association, said the negative attention may lead some doctors to quit Medicare.
"There's already issues with reimbursements," he said, "and now you're getting blamed for a selection of medication you have very little power to pick."
Some providers attribute their unusual billing patterns to an unusual mix of patients. One is Dr. Gregory Lorkowski, an optometrist in Dallas with no disciplinary history.
In 2012, he billed Medicare for 1,290 comprehensive eye exams on just 285 patients – the highest per-patient rate in Texas. He also had the nation's highest per-patient rate of microfluidic tear analysis. Medicare paid him about $154,000 for the two types of procedures.
The rates, Lorkowski said, reflected a high percentage of patients with severe diabetes. "Things I see in this clinic you should not see in America today," he told The News.
Lorkowski's per-patient exam rate is much closer to that of ophthalmologists – who, unlike optometrists, are physicians. He said that's because he does diagnostic work that peers frequently refer to ophthalmologists. The newspaper's analysis showed that he does more comprehensive exams per patient than any ophthalmologist in the state.
Karen Weintraub, a leading expert in health care fraud and waste whose company advises private insurers, said billing monitors analyze data for highly unusual patterns.
"We definitely look at statistical outliers pretty much for everything," said Weintraub, an executive vice president at Healthcare Fraud Shield, a Missouri-based company that specializes in fraud-detection software.
Weintraub, who did not review The News' findings, cautioned that outlier detection merely indicates potential fraud or overuse. But, in general, she said, "if you move forward and you do a full review, you'll usually find the top outliers have something going on."
(Dallas Morning News staff writer Daniel Lathrop contributed to this report.)
(c)2014 The Dallas Morning News
Visit The Dallas Morning News at www.dallasnews.com
Distributed by MCT Information Services