6 Michigan Pain Doctors charged w/ $500M opioid/insurance scheme

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gaseous_clay

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Six Detroit-area doctors charged in $500M opioid scheme

The article is a headline grabber but read the attached indictment (PDF). This is basically what happens at most pain practices that offer interventional procedures and opioid therapy. The opioid doses and procedures mentioned in the indictment are not completely unreasonable, yet the feds are charging these guys with doing things outside of medical necessity.

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It’s hard to follow that.

What exactly did those guys do??
 
i think the head guy was a general surgeon who started this pain clinic in 2013.... he claims to have pain certification as a fellow of interventional pain.... a few of the docs have questionable credentials in terms of board certification.... at least one was not board certified in anesthesia or pain but was practicing both. if you look at the their website they have a urine quantitative lab and tout an in house pharmacy and also durable medical goods. billing out 500 millions in a five year span seems excessive for a practice with two clinics and a surgical center (if it is indeed a surgical center or not). seems like a lot of these cases in the news have to do with fraudulent abuse of ancillaries, where docs are trying to make as much money on each patient as possible with unnecessary charges...
 
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What is with these guys and Lambos?

And what's with all these people from India being the Best Samaritan of All Time and then turning out to be crooked sleaze?
 
$100 million in charges/5x medicare fee schedule/ 5 years / 5 docs = $800k per year per doc X 50% overhead = 400k doc/yr

Pain med is under the microscope

Edit -top number was off- 2 million. Still not enough for me to live there haha
 
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$100 million in charges/5x medicare fee schedule/ 5 years / 5 docs = $800k per year per doc X 50% overhead = 400k doc/yr

Pain med is under the microscope
Nah...There's something going on here, the average Joe Pain MD is not doing.

"Dr. Bothra amassed a $35 million fortune, including an island, a mansion and an overseas bank account stuffed with cash....Bothra has $7.6 million in a retirement account...$1.6 million home and another home — listed for sale for $1.9 million — on a private island ...failed to tell the government about his real estate company that owns commercial and residential properties that are worth a combined $3 million...also failed to tell court officials about an Indian bank account with more than $1.2 million...net worth at as much as $35 million."

"Bothra's clinics 'sought to bill insurance companies for the maximum number of services and procedures possible with no regard to the patients’ needs,' prosecutors alleged."

'Mastermind' of opioid scheme bought island, stashed millions overseas
 
What is the deal with the "disheveled" look? The report says the docs had pockets turned inside out and hair in disarray for the mug shot. Just too strange... Why would they allow that "look" to be captured for the prosecutors?
 
How did the feds have evidence that they were trading pills for shots? Also, did they own an MRI center too? Because I don’t see how ordering an MRI would be considered outside of medical necessity if they or their relatives didn’t have shares in a center. I also wonder if it was an employee that blew the whistle.
 
$100 million in charges/5x medicare fee schedule/ 5 years / 5 docs = $800k per year per doc X 50% overhead = 400k doc/yr

Pain med is under the microscope
er, multiply that by 5. its $500 million, no $100 million.

so technically, using your formula, $2 million doc/year.
 
The “trading pills for shots” allegation is somewhat disturbing.

We ALL do that to some extent .

“Can I have something for pain?”

“We need to find a non medication way to attempt to treat this. Let’s try an ESI first”

Is that viewed as a trade ?
 
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The “trading pills for shots” allegation is somewhat disturbing.

We ALL do that to some extent .

“Can I have something for pain?”

“We need to find a non medication way to attempt to treat this. Let’s try an ESI first”

Is that viewed as a trade ?

Guess that explains your username.

Give them a shot of Toradol and an Rx for Lyrica with the free start card. Get the PT or home ex program going. If fails that then do injection. Where do tou get opiates in that equation?
 
Guess that explains your username.

Give them a shot of Toradol and an Rx for Lyrica with the free start card. Get the PT or home ex program going. If fails that then do injection. Where do tou get opiates in that equation?


Just that. They ask, you say no, outline conservative tx, proceed to do that, pt comes back with no relief
 
Guess that explains your username.

Give them a shot of Toradol and an Rx for Lyrica with the free start card. Get the PT or home ex program going. If fails that then do injection. Where do tou get opiates in that equation?

You must have a great patient population if that doesn’t happen to you ever.
 
I have a guy who is an obvious POS that's been on opiates since he was 21 or something, and for like 8 different Dx. Referred to me by an inhouse MD that is new to our practice. When I asked him why he needs opiates he says, "I had a wreck in '96, I got bad knees, wrist hurts, etc."

"You're 45 yo dude. You've been on opiates since you were in your early 20s. You are going to have to prove to me that you need them bc I don't just keep ppl on opiates. What is your biggest problem right now?"

"My back."

He has facet arthropathy and a PE consistent with facetogenic pain. I put him in PT and we schedule facet CSI for like a month out. He no shows. I see him in the clinic and we reschedule. He no shows again.

I release him from my clinic.

Is that pills for shots? No...

The rationale is that I try to use a well rounded program to get OFF opiates, and if you don't do it you can't receive my help or my time. I have tons of ppl in my clinic who I can help, and who participate fully. Pts like him can eff off bc my energy is limited and I'd prefer to help ppl not harm them.
 
I have a guy who is an obvious POS that's been on opiates since he was 21 or something, and for like 8 different Dx. Referred to me by an inhouse MD that is new to our practice. When I asked him why he needs opiates he says, "I had a wreck in '96, I got bad knees, wrist hurts, etc."

"You're 45 yo dude. You've been on opiates since you were in your early 20s. You are going to have to prove to me that you need them bc I don't just keep ppl on opiates. What is your biggest problem right now?"

"My back."

He has facet arthropathy and a PE consistent with facetogenic pain. I put him in PT and we schedule facet CSI for like a month out. He no shows. I see him in the clinic and we reschedule. He no shows again.

I release him from my clinic.

Is that pills for shots? No...

The rationale is that I try to use a well rounded program to get OFF opiates, and if you don't do it you can't receive my help or my time. I have tons of ppl in my clinic who I can help, and who participate fully. Pts like him can eff off bc my energy is limited and I'd prefer to help ppl not harm them.

But don’t you feel like that’s one end of the spectrum? Of course, he’s a drug seeking patient, non compliant, poor prognosis for ever being functional and productive

I have so many who are not like that, but at the same time who I’ve either inherited or started on a little medication (under 60 morphine equivalent) while doing injections every once in a while (esi or rfa every 6-8 months or so) and they do well and are functional and maintain jobs. Is that viewed as trading shots for pills? That’s my concern
 
But don’t you feel like that’s one end of the spectrum? Of course, he’s a drug seeking patient, non compliant, poor prognosis for ever being functional and productive

I have so many who are not like that, but at the same time who I’ve either inherited or started on a little medication (under 60 morphine equivalent) while doing injections every once in a while (esi or rfa every 6-8 months or so) and they do well and are functional and maintain jobs. Is that viewed as trading shots for pills? That’s my concern

I think this specific subject is 99.9% of the time going to be justifiable through documentation and will not be considered "pills for shots." I think it is a rare set of circumstances, like a couple guys billing $500 million that set off the alarms.

FWIW - I still don't see where that number came from...

Edit - I have a small handful of pts that ONLY receive opiates from me, without also getting PT, ablations, occasional ESI, etc. Passive management with just opiates is not common in my practice.
 
Just that. They ask, you say no, outline conservative tx, proceed to do that, pt comes back with no relief
Does that mean that they expect opioids from you then?

From the start, I make sure that patients never expect opioid therapy from me (with exception of palliative pain management).

If you do start them on low dose therapy, the way that I sort out “pills for shots” is by documenting and making it clear that these are two separate therapies. Generally speaking, the opioids become chronic - ie maintenance therapy - and injections are only as needed, for pain exacerbation from shoveling snow, for ex.

This does of course reduce reimbursement...
 
er, multiply that by 5. its $500 million, no $100 million.

so technically, using your formula, $2 million doc/year.

And that’s not even considering their charges to private insurance. If you look at private payers as 1.2 x Medicare rate and let’s say around half their patients are Medicare you get closer to $5 million a year. Definitely not a normal medical practice.
 
“Can I have something for pain?”

“We need to find a non medication way to attempt to treat this. Let’s try an ESI first”

Is that viewed as a trade ?
I doubt it. But making everyone go through every intervention their insurance will pay for, when you know it's not indicated, in exchange for pills, is. For example, you tell them they can't have the opiates they want and instead they need interventions. Then they tell you they already had ESIs, mbb/rfa, SIJ, stim trial, trigger points already and they didn't help. You tell them, too bad, you can't have opiates unless you do these shots we both know are futile, but if you agree to the shots (that you know are futile) you'll give them whatever opiates they want. The right thing to do, would be to not do futile shots and either not give them opiates either (if you think that's also futile in their case) or give them the opiates if you think they are indicated without coercing a patient into futile care.

Here, think about this. You're the Feds. A whistleblower from docs office tells you the doc is essentially selling pills for procedures. You send in 5 undercover officers all with normal backs, no pain and normal MRIs. You give them a script to ask for opiates and tell the doc they've had every procedure known to man and they didn't help. If the doc says, "By the looks of it you don't need the injections, I agree. But your imaging is so normal I see no reason you need a lifetime of opiates, either," then you pass, they're not likely to get too excited about that. On the other hand, if you recommend some sort of treatment that is medically justified, you're probably okay. On the other hand, if you ignore that they just told you their back doesn't hurt right now and ignore their stone cold normal MRI and say, "You have to go through a round of injection if you want pills," then you fail. They know they're on to something and they're going to dig deeper.

Remember, the agent just told you the injections are futile, unnecessary and he's teeing it up for the doc to essentially confess to a fraudulent care for pills scheme. And he's got it all on tape. Then they send in 5 more agents demanding narcs, and again, the doc coerces all of them to do a bunch more treatments the agents can later prove were obviously futile (they told you their back didn't hurt today, stone cold normal imaging, records + verbal report that same treatments were tried multiple times and did nothing or made the pain worse) then you're screwed.

Just do the right thing for the patient in front of you and what seems reasonable and you shouldn't have to worry. If doing that somehow allows you to earn 10 times MGMA, they reconsider that what you think is the right thing, might not be, according to the feds and likely a jury of people making 1/10th of MGMA. Single events and borderline or questionable gray area stuff is not likely to get you into trouble. You have to be doing some really sleazy s**t on a major scale to get the Feds attention and justify them taking you up as a federal case, considering all the other high dollar scams out there, for them to go after. In the same way an IRS agent will get laughed out of his job for prosecuting someone for not reporting $50 of taxes on tip money, the DEA & US attorney's have to be able to justify spending years and hundreds of thousands of dollars in going after you. One disgruntled patient or one borderline ESI, isn't likely to do it.

Remember the old saying, "Pigs get fat, hogs get slaughtered." There's a lot of truth to it.
 
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Given that we don’t know all the details of the evidence the feds have, but the “pills for shots” concept can be applied liberally to fit all the scenarios mentioned above. The feds set this standard. I just hope they evaluated all the evidence fairly and accurately prior to arresting these guys because a blanket policy of establishing criminal intent for all physicians who prescribe opioids will set a bad precedent.
 
I was told by a Medicare investigator that they review all the top 10 prescribers and the top 10 reimbursed physicians because it is easier to recover damages from them. No point going after someone making $350K even if he is doing 100% fraud.

Also bigger the fish the bigger the career boost for the Atoorneh General , DEA inverstigator etc.

Just don’t do anything that is not black and white.
 
The “trading pills for shots” allegation is somewhat disturbing.

We ALL do that to some extent .

“Can I have something for pain?”

“We need to find a non medication way to attempt to treat this. Let’s try an ESI first”

Is that viewed as a trade ?
If I feel opioid tx is a safe and effective option, then I offer it as an option. Going through a catalogue of interventions first does not justify or make opioids any more safe and effective.
 
Not associating with opioid prescribing but many patients have undergone "procedures" that did not help because they were not properly performed. I have reviewed charts with mbb needles several inches from target, RFA needles in subQ tissue nowhere near spine. I'm not offering them opioids but I do believe that it is not over utilization to offer to do a procedure correctly that I believe is indicated. I'm also not billing millions to pay for my island.
 
I am familiar with several pain practices that offer pills-for-shots, pills for in-house advanced UDS, and pills for traction machines. One charlatan that was 5 miles away from me still does this today. Is it fraud? Of course. Will they get caught by the government? Probably not.
 
Do you guys think it’s smart to reach out to the local dea agent to discuss rules, policies, procedures, and verify in fact your practice is doing things appropriately ?

Or is this just giving your practice attention that it didn’t need to begin with
 
The DEA will usually not involve themselves with assuring a practice is following rules: they simply expect you to know and follow them, and if you do not, you become a target. But it is rare for the DEA to actually target physicians alone- usually they involve the state attorney generals and Boards of Medicine.
 
Not associating with opioid prescribing but many patients have undergone "procedures" that did not help because they were not properly performed. I have reviewed charts with mbb needles several inches from target, RFA needles in subQ tissue nowhere near spine. I'm not offering them opioids but I do believe that it is not over utilization to offer to do a procedure correctly that I believe is indicated. I'm also not billing millions to pay for my island.
I agree with this. If a procedure was done improperly or let's say, many many years ago and maybe they have a new problem, absolutely you could do a retrial of something that previously may not have work, but the key is that you can document a valid reason the new attempt is expected to work better than the previous. I doubt the fraudsters are documenting any of that.
 
Do you guys think it’s smart to reach out to the local dea agent to discuss rules, policies, procedures, and verify in fact your practice is doing things appropriately ?
It's smart to verify that your practice is doing things appropriately. But calling the DEA to come in is not the right way to do it, in my opinion. The feds don't want to waste their time unless they have something to prosecute. They'd likely just tell you to go online read their rules, regulations and state/fed medical practice laws. In my opinion, you only open yourself up to them finding something by inviting them in. Verify by other methods.
 
$100million/year in CHARGES may not be that exorbitant for a practice of at least 5 physicians in three different clinics including laboratory, imaging, and facility fees.

As far the 77-year old Dr. Bortha's fortune, perhaps his family has extensive means. Also, it seems like if he was a recipient of the Padma Shri award and Indianan politician he likely has had numerous investment opportunities.

In regard to the medical aspect, the DEA and medical board will determine fate.

Will be interesting to see how this turns out and will likely take years for final 'justice.'

n.b. I do not know any of these people
 
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$100million/year in CHARGES may not be that exorbitant for a practice of at least 5 physicians in three different clinics including laboratory, imaging, and facility fees.

As far the 77-year old Dr. Bortha's fortune, perhaps his family has extensive means. Also, it seems like if he was a recipient of the Padma Shri award and Indianan politician he likely has had numerous investment opportunities.

In regard to the medical aspect, the DEA and medical board will determine fate.

Will be interesting to see how this turns out and will likely take years for final 'justice.'

n.b. I do not know any of these people

You are clearly misguided. Bonkers.
 
$100million/year in CHARGES may not be that exorbitant for a practice of at least 5 physicians in three different clinics including laboratory, imaging, and facility fees.

As far the 77-year old Dr. Bortha's fortune, perhaps his family has extensive means. Also, it seems like if he was a recipient of the Padma Shri award and Indianan politician he likely has had numerous investment opportunities.

In regard to the medical aspect, the DEA and medical board will determine fate.

Will be interesting to see how this turns out and will likely take years for final 'justice.'

n.b. I do not know any of these people

$100 million for 5 physicians? That's significantly more than my entire practice of...what 20 doctors, and I'm like one of 3 nonsurgeons...

Find me ONE pain physician billing $10 million! The spine surgeons in my group don't even bill $10 million per year.

Edited to fix my numbers. We have just about 25 doctors but not all are full time.
 
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$100million/year in CHARGES may not be that exorbitant for a practice of at least 5 physicians in three different clinics including laboratory, imaging, and facility fees

Doubt they owned a surgery center. Michigan has pretty stringent CON statutes. Could have owned shares in an MRI facility though.
 
Prosecuting attorneys report charges, not actual dollars earned. You'll see this in every indictment of every physician ever charged. We all know that what we charge is not what we collect, and what we collect is not what we actually earn, to be able to keep. And the Feds know that too. But they report the grossly inflated "charges" number, which is usually at least 6 or more times higher, knowing it will create a shock value with a jury of average citizens, that make $40,000 per year.

"OMG, this doctor charged 1.2 million dollars. 1.2 million, did you hear that, 1.2 MILLION!"

"No way that's clean money. Greedy SOB, convict!

Turns out, $1.2 million charged, equals, $400,000 collected, which after overhead is $200,000 actually earned which is actually half of the average Pain MD salary.

You can portray that doctor a "conservative, modest person, who eased the pain of the suffering and put patient care above profits while being content to earn half of what he could have." Or you can make that doctor a "greedy, Porsche driving SOB, who charged the tax payers for $1.2 million while turning away desperate Medicaid patients in desperate need of care." Good prosecuting attorneys are masters of persuasion and they'll do this kind of thing all day long, precisely because it's effective.
 
$100million/year in CHARGES may not be that exorbitant for a practice of at least 5 physicians in three different clinics including laboratory, imaging, and facility fees.

As far the 77-year old Dr. Bortha's fortune, perhaps his family has extensive means. Also, it seems like if he was a recipient of the Padma Shri award and Indianan politician he likely has had numerous investment opportunities.

In regard to the medical aspect, the DEA and medical board will determine fate.

Will be interesting to see how this turns out and will likely take years for final 'justice.'

n.b. I do not know any of these people

Prosecuting attorneys report charges, not actual dollars earned. We all know that what we charge is not what we collect, and what we collect is not what we actually earn, to be able to keep. And the Feds know that too. But they report the "charges" knowing it will create a shock value with a jury of average citizens, that make $40,000 per year.

"OMG, this doctor charged 1.2 million dollars. 1.2 million, did you hear that, 1.2 MILLION!"

"Greedy SOB, convict!

Turns out, $1.2 million charged, equals, $400,000 collected, which after overhead is $200,000 actually earned which is actually half of the average Pain MD salary.
okay, take both those aspects into account.



how much extra do you figure they charged non-Medicare insurance?

for example, if Medicare makes up 30% of one's practice, and one charges insurance 1.2 + the base set medicare fees. just to be sensational, would a number of $2 Billion be worrisome ($500 million from Medicare, 1.5 billion from private insurance) ?
 
okay, take both those aspects into account.



how much extra do you figure they charged non-Medicare insurance?

for example, if Medicare makes up 30% of one's practice, and one charges insurance 1.2 + the base set medicare fees. just to be sensational, would a number of $2 Billion be worrisome ($500 million from Medicare, 1.5 billion from private insurance) ?
Billions?

Lol

Come on, now.
 
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Prosecuting attorneys report charges, not actual dollars earned. You'll see this in every indictment of every physician ever charged. We all know that what we charge is not what we collect, and what we collect is not what we actually earn, to be able to keep. And the Feds know that too. But they report the grossly inflated "charges" number, which is usually at least 6 or more times higher, knowing it will create a shock value with a jury of average citizens, that make $40,000 per year.

"OMG, this doctor charged 1.2 million dollars. 1.2 million, did you hear that, 1.2 MILLION!"

"No way that's clean money. Greedy SOB, convict!

Turns out, $1.2 million charged, equals, $400,000 collected, which after overhead is $200,000 actually earned which is actually half of the average Pain MD salary.

You can portray that doctor a "conservative, modest person, who eased the pain of the suffering and put patient care above profits while being content to earn half of what he could have." Or you can make that doctor a "greedy, Porsche driving SOB, who charged the tax payers for $1.2 million while turning away desperate Medicaid patients in desperate need of care." Good prosecuting attorneys are masters of persuasion and they'll do this kind of thing all day long, precisely because it's effective.

$1.2 million billed does make me bat an eye. We're talking much, much more than that.
 
I did simple math, emd.

500 million billed to Medicare.

if Medicare is 30% of your panel, then 70% of what you see and bill is private insurance. ie 500 x .7/.3= 1.1 billion. x 1.2 cost of medicare, and you get actually 1.4 billion charged to private insurance. +500 million equals 1.9 billion (and yes I rounded up.)

fwiw, the link to that house that he owns now shows it listed at $315K. the previous listing, which obviously has been currently revised, was for 1.9 million.

https://www.zillow.com/homedetails/6579-Longworth-Dr-Waterford-MI-48329/70858342_zpid/
 
I did simple math, emd.

500 million billed to Medicare.

if Medicare is 30% of your panel, then 70% of what you see and bill is private insurance. ie 500 x .7/.3= 1.1 billion. x 1.2 cost of medicare, and you get actually 1.4 billion charged to private insurance. +500 million equals 1.9 billion (and yes I rounded up.)

fwiw, the link to that house that he owns now shows it listed at $315K. the previous listing, which obviously has been currently revised, was for 1.9 million.

https://www.zillow.com/homedetails/6579-Longworth-Dr-Waterford-MI-48329/70858342_zpid/
I'm sure if the prosecuting lawyers could have claimed they were responsible for "billions" of anything, that would have been in the first sentence to bias the jury against the defendants. Regardless, I agree the numbers look excessive for a typical IPM practice and I'm not defending this crew, as I know nothing about them. Still, there's still no need to claim "amount billed," which inflates the physician's income by at least 600%, other than to falsely inflame the jury, who will automatically assume the amount "billed" equals amount earned. It's not. But every indictment against any physician I've ever seen leads with "Billed Medicare for 'X' dollars" which we all know is not an accurate measure of physician income, instead about 6 times greater. You could continue seeing your same amount of patients, while making about MGMA average and suddenly increase your fee schedule and therefore "charges" to Medicare next year by 10 times, and I'd still not make a penny more.
 
I don't disagree that it is meant to encourage outrage.

obviously, you can agree that the feds have to make people empathetic to their side by showing that these doctors were not doing a "normal" practice.

if they did not claim some outrageous number, people like you and I - and the average American - would immediately critique the feds for being horrible mean vigilantes that need to stay in their lane and stop targeting poor doctors making just barely enough to get bus fare to get their kids to the food kitchen and pay for cardboard boxes for shelter, all the while doing charity work for indigents...
 
Doubt they owned a surgery center. Michigan has pretty stringent CON statutes. Could have owned shares in an MRI facility though.

The indictment lists 'The Pain Center USA, PLLC' and 'Interventional Pain Center, PLCC'

$100 million for 5 physicians? That's significantly more than my entire practice of...what 20 doctors, and I'm like one of 3 nonsurgeons....

Totally agree that for professional fees related to wRVU for 5-physicans close to $100 million/year is likely impossible. However, if the charges are for 3-clinics, laboratory and interventional clinic, perhaps not so much.

It would be interesting to see the breakdown of where the numbers arose.

okay, take both those aspects into account...for example, if Medicare makes up 30% of one's practice, and one charges insurance 1.2 + the base set medicare fees. just to be sensational, would a number of $2 Billion be worrisome ($500 million from Medicare, 1.5 billion from private insurance) ?

Insurance mix varies greatly by practice. Many practices in our region are around 75% MC/MCD/BC.

Also, charges vary greatly by practice: How to Set a Standard Fee Schedule for Your Practice for links to fee analyzers and fee references.

Not defending these guys, and they could very well be guilty of all charges, but they are still innocent until proven otherwise.

Cheers
 
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