The doctor who bills the most for Medicare in the country is a South Florida ophthalmologist whose offices were twice raided last year by the FBI and whose generous political contributions and cozy relationship with a New Jersey senator, Robert Menendez, are under investigation by federal public corruption prosecutors, a New York Times analysis of Medicare data shows.
Data released Wednesday by the Centers for Medicare and Medicaid Services show Dr. Salomon E. Melgen, 59, who moved to Florida from the Dominican Republic in the late 1970s, received $21 million in Medicare reimbursements in 2012 alone. The doctor billed mostly for Lucentis, a medication used to treat macular degeneration made by
a company that pays generous rebates to its doctors.
He is a central figure in two different federal investigations. In January and October last year, FBI agents were spotted carrying
boxes out of his offices.
Dr. Melgen’s lawyer warned against presuming that the doctor’s high bills to Medicare meant he was engaged in fraud. In a statement released late Tuesday, his lawyer said the large reimbursements from the Centers for Medicare and Medicaid Services, known as CMS, were easily explained: The doctor has a big practice.
Dr. Melgen has 30 employees working for his company, Vitreo Retinal Consultants, in four different Florida offices.
“At all times, Dr. Melgen billed in conformity with Medicare rules,” the doctor’s lawyer, Kirk Ogrosky, a former Medicare fraud prosecutor, said in a statement. “While the amounts in the CMS data release appear large, the vast majority reflects the cost of drugs. The facts are that doctors receive 6 percent above what they pay for drugs, the amount billed by physicians is set by law, and drug companies set the price of drugs, not doctors.”
According to the records, Dr. Melgen gave 37,000 doses of Lucentis, also known as Ranbizumab, to 645 different patients. Overall, he had 894 patients who underwent 92,000 procedures.
The F.B.I. started an investigation of Dr. Melgen last year, because he was accused of overbilling by “multi-dosing” a vial of medication that was supposed to be used for a single patient, but could be spread out among several. Under federal rules, the doctor was supposed to have thrown the extra medication out.
The doctor defended the practice, saying that federal law required a separate bill for each dose.
Dr. Melgen was forced to pay back $9 million he was suspected of overbilling. When faced with the federal investigation, he fought back by filing a federal lawsuit against the U.S. Secretary of Health and Human Services to recover the money. The 2013 lawsuit, which noted that 70 percent of Dr. Melgen’s clientele are Medicare patients, alleged that the government retaliated for the civil action by suspending the doctor’s Medicare payments.
Dr. Melgen catapulted from obscurity to notoriety last year, when questions were raised about his close relationship with Mr. Menendez, (Senator -D) who had received free rides on the doctor’s private jet and stayed at the doctor’s home in a luxury resort complex in the Dominican Republic.
Dr. Melgen donated more than $700,000 to the senator’s political action committee, and Senator Menendez publicly and privately
helped his friend with business disputes. The senator made calls on the Mr. Melgen’s behalf to the U.S. Department of Health and Human Services in the dispute over the injection dosing and advocated on behalf of the doctor during a Senate hearing into a port security contract in the Dominican Republic.
The hearing involved a port security company that Dr. Melgen had purchased in his native country in the hopes that the Dominican Republic would start screening every container on every outbound vessel. The Customs agency there refused to honor the contract, and Senator Menendez urged U.S. officials to get involved.
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