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Rhode Island’s ‘Medicare Millionaires’

Thursday, April 10, 2014

 

More than 4,000 doctors and other providers of health care services in Rhode Island received nearly $260 million in Medicare reimbursements in 2012, according to new federal data released yesterday.

The data, the first of its kind available in decades, pinpoints where Medicare dollars are going and which doctors and other health care providers are the top recipients—including many so-called ‘Medicare millionaires’ who bill $1 million or more annually. Of $64 billion issued in individual reimbursements nationwide, a third went to under 3 percent of doctors, with nearly 4,000 physicians billing at rates of $1 million or more annually, according to Bloomberg.

In Rhode Island, seven doctors billed at $1 million or more and another three received just under seven figures in Medicare reimbursements, according to a GoLocalProv analysis of the federal data. Overall, a quarter of the nearly $260 million spent went to just 11 percent of doctors and other health care providers. (See the slides for the list of the top 20.)

Top doctor faces fraud investigation

The top doctor listed is Fathalla M. Mashali, an anesthesiologist who received $3.4 million for an estimated 727 patients in 2012. That’s still significantly less than the $13.5 million Mashali requested from Medicare, when he was eligible for no more than $3.6 million, federal records show.

Last month, federal authorities announced that a doctor identified as Fathalla Mashali, who was licensed in both Rhode Island and Massachusetts, had been charged with nine counts of Medicare fraud. Mashali, who ran New England Pain Institute, P.C., with multiple locations in both states, allegedly trained his employees “to overbill the Medicare program,” according to a new release issued by the U.S. Attorney for Massachusetts. Federal prosecutors allege that the doctor “overbooked patient appointments,” often spending less than 10 minutes with a patient and often neglecting to perform any physical examination.

Also, in 2010, the U.S. Department of Labor sued Mashali for failing to contribute more than $6 million to his business’ pension plan, which it described as a violation of the Employee Retirement Income Security Act. Federal authorities alleged that Mashali diverted the money to benefit himself and his business, which had filed for bankruptcy in 2008. (At the time his business was Northern Rhode Island Anesthesia Associates P.C.)

The Rhode Island Department of Health database of licensed doctors lists one Fathalla M. Mashali, whose license was actually suspended last year after state authorities concluded that he had not followed proper procedures in prescribing pain medication to six patients who later died.

Mashali had been practicing in Rhode Island since 1996, according to state records. Attempts to reach him at an office listed in federal records at East Providence were unsuccessful yesterday.

Reining in costs

The release of the data is an opportunity to track how Medicare dollars are being spent and identify ways to make health care more affordable, according to Tom Sgouros, a progressive policy analyst who has studied health care costs. “Now that we have a path to covering almost everybody, we need a path to adequate cost control,” Sgouros said.

Sgouros said those doctors who are overbilling are increasing costs for everyone else in the system, especially those who can least afford it.

“Behind every person who is making a zillion dollars from health care is a company that can’t afford to insure its employees or a city that can’t … make its health care payment,” Sgouros said. “The idea that somebody can become fabulously rich off health care is a burden on everybody else.”

But Steven DeToy, the spokesman and lobbyist for the Rhode Island Medical Society, said it’s unfortunate that the media has focused on those doctors who are abusing the system and facing allegations of fraud. “For every one of those, there’s probably thousands of doctors doing it the right way,” DeToy said.

DeToy cautioned against drawing too many conclusions from the data, noting that it is a glimpse of just one year’s worth of spending and does not identify trends or patterns over a period of time. “It’s like a public opinion survey. It’s a snapshot at that moment,” DeToy said.

The data may not be able to answer some questions, but at least it allows the public and analysts to ask the right kinds of questions, Sgouros added. “You can’t really tell from the list who’s a scammer and who’s not but you can use it as a hint,” he said.

While some praised the new database as a step forward in transparency and accountability, one local commentator says it is just another example of how dysfunctional health care spending becomes when the government is involved.

“It’s astonishing to think about what happens when government meddles. We should know what doctors are charging for services upfront, as part of the decision making process. Instead, it’s like we have to have government pay the bill, then pressure the administration for transparency, and then wade through a massive database,” said Justin Katz, the research director for the Rhode Island Center for Freedom and Prosperity and the managing editor for the Ocean State Current.

“And at the end of the day, we can only hope to catch obvious fraud or careless scammers,” Katz added. “When you add in the government requirements and price fixing that limit the supply of doctors, the incentive and opportunity increase to work the system.”

Cracking down on Medicare fraud

The Centers for Medicare and Medicaid Services said the new database would allow public to track $77 billion in Medicare payments to more than 880,000 health care providers nationwide, saying the release has given consumers “unprecedented transparency” on how the Medicare system work. In all spending for 6,000 different types of services is listed, according to a news release.

“Data transparency is a key aspect of transformation of the health care delivery system,” CMS Administrator Marilyn Tavenner said in a news release. “While there’s more work ahead, this data release will help beneficiaries and consumers better understand how care is delivered through the Medicare program.”

The agency also already has in place programs that target fraud, abuse, waste, overpayments, and unusual billing patterns, according to information provided in response to a series of questions from GoLocalProv.

Estimates of  Medicare fraud vary. A 2010 Government Accountability Office report pegged it at nearly 10 percent of the annul $500 billion in Medicare spending for the year while the U.S. Attorney General has said the amount could be nearly double that, according to a May 2012 Fobes.com report.

Stephen Beale can be reached at bealenews@gmail.com. Follow him on Twitter @bealenews

 

Related Slideshow: Top 20 Medicare Payment Recipients in RI

Below are the top 20 highest recipients of Medicare reimbursements in 2012, listed in order from least to greatest. The list includes doctors, ambulance services, and health care businesses. Two municipal ambulance services are also listed. The data, the first of its kind available in decades, was released by federal authorities yesterday.

Prev Next

20. Bayside Endoscopy LLC

Ambulatory Surgical Center

33 Staniford St., Providence

2012 Medicare Payment Data

Total Payment Amount: $906,270.96

Total Amount Requested: $4,973,041.00

Total Amount Allowed: $1,131,865.04

Number of Patients: 2,297

Prev Next

19. Scott Triedman

Radiation Oncology

825 N. Main St., Providence

2012 Medicare Payment Data

Total Payment Amount: $913,292.76

Total Amount Requested: $3,890,550.00

Total Amount Allowed: $1,146,103.50

Number of Patients: 221

Prev Next

18. Richard Bryan

Ophthalmology

120 Dudley St., Providence

2012 Medicare Payment Data

Total Payment Amount: $952,468.78

Total Amount Requested: $1,864,734.00

Total Amount Allowed: $1,214,139.31

Number of Patients: 688

Prev Next

17. Timothy Shafman

Radiation Oncology

115 Cass Ave., Woonsocket

2012 Medicare Payment Data

Total Payment Amount: $956,736.41

Total Amount Requested: $3,932,391.04

Total Amount Allowed: $1,200,057.52

Number of Patients: 195

Prev Next

16. City of Warwick

Ambulance Service Supplier

140 Veterans Memorial Dr., Warwick

2012 Medicare Payment Data

Total Payment Amount: $998,365.17

Total Amount Requested: $2,066,796.57

Total Amount Allowed: $1,257,678.93

Number of Patients: 1,805

Prev Next

15. John Przygoda

Hematology/Oncology

215 Toll Gate Rd., Warwick

2012 Medicare Payment Data

Total Payment Amount: $1,004,675.10

Total Amount Requested: $2,066,796.57

Total Amount Allowed: $1,261,926.16

Number of Patients: 503

Prev Next

14. Candescent Eye Surgicenter LLC

Ambulatory Surgical Center

444 Quaker Ln., Warwick

2012 Medicare Payment Data

Total Payment Amount: $1,006,561.31

Total Amount Requested: $2,627,000.00

Total Amount Allowed: $1,271,196.23

Number of Patients: 1,085

Prev Next

13. Harold Woodcome

Ophthalmology

690 Eddy St., Providence

2012 Medicare Payment Data

Total Payment Amount: $1,016,205.81

Total Amount Requested: $1,830,849.25

Total Amount Allowed: $1,287,778.13

Number of Patients: 610

Prev Next

12. Magdelena Krzystolik

Ophthalmology

1 Randall Sq., Providence

2012 Medicare Payment Data

Total Payment Amount: $1,179,376.11

Total Amount Requested: $2,298,560.00

Total Amount Allowed: $1,493,926.23

Number of Patients: 845

Prev Next

11. Daniel Esmaili

Ophthalmology

690 Eddy St., Providence

2012 Medicare Payment Data

Total Payment Amount: $1,206,315.63

Total Amount Requested: $2,822,677.88

Total Amount Allowed: $1,531,958.89

Number of Patients: 1,040

Prev Next

10. Robert Janigian

Ophthalmology

120 Dudley St., Providence

2012 Medicare Payment Data

Total Payment Amount: $1,239,967.62

Total Amount Requested: $2,404,494.00

Total Amount Allowed: $1,579,534.71

Number of Patients: 707

Prev Next

9. City of Providence

Ambulance Service Supplier

25 Dorrance St., Providence

2012 Medicare Payment Data

Total Payment Amount: $1,676,474.04

Total Amount Requested: $3,161,123.57

Total Amount Allowed: $2,101,837.97

Number of Patients: 2,594

Prev Next

8. New England Ambulance Service Inc.

Ambulance Service Supplier

31 Manuel Ave., Johnston

2012 Medicare Payment Data

Total Payment Amount: $1,776,635.86

Total Amount Requested: $5,659,733.00

Total Amount Allowed: $2,283,383.80

Number of Patients: 4,007

Prev Next

7. Universal Ambulance Service Inc.

Ambulance Service Supplier

457 Douglas Ave., Providence

2012 Medicare Payment Data

Total Payment Amount: $1,884,482.01

Total Amount Requested: $4,342,289.00

Total Amount Allowed: $2,373,620.07

Number of Patients: 2,140

Prev Next

6. Professional Ambulance LLC

Ambulance Service Supplier

52 River Ave., Providence

2012 Medicare Payment Data

Total Payment Amount: $1,958,350.32

Total Amount Requested: $4,714,047.00

Total Amount Allowed: $2,451,287.41

Number of Patients: 1,559

Prev Next

5. Jonah Licht

Internal Medicine

100 Highland Ave., Providence

2012 Medicare Payment Data

Total Payment Amount: $3,169,359.75

Total Amount Requested: $12,629,104.00

Total Amount Allowed: $4,041,718.40

Number of Patients: 652

Prev Next

4. Fathalla Mashali

Anesthesiology

42 Hemingway Dr., East Providence

2012 Medicare Payment Data

Total Payment Amount: $3,470,467.27

Total Amount Requested: $13,595,131.73

Total Amount Allowed: $3,698,641.98

Number of Patients: 727

Prev Next

3. Med Tech Ambulance Service Inc.

Ambulance Service Supplier

19 Mendon Ave., Pawtucket

2012 Medicare Payment Data

Total Payment Amount: $4,650,676.77

Total Amount Requested: $9,264,381.25

Total Amount Allowed: $5,834,893.12

Number of Patients: 6,291

Prev Next

2. East Side Clinical Lab Inc.

Clinical Laboratory

10 Risho Ave., East Providence

2012 Medicare Payment Data

Total Payment Amount: $7,133,560.47

Total Amount Requested: $25,254,372.28

Total Amount Allowed: $7,170,862.69

Number of Patients: 40,842

Prev Next

1. Dominion Diagnostics LLC

Clinical Laboratory

211 Circuit Dr., North Kingstown

2012 Medicare Payment Data

Total Payment Amount: $12,551,313.22

Total Amount Requested: $15,083,697.99

Total Amount Allowed: $12,616,086.69

Number of Patients: 20,736

 
 

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