CSMonitor – An epic case of medical fraud – and the agent who cracked it

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This is the story of how a Miami psychiatrist managed to beat the system year after year, but finally met his match in a health-care fraud investigator named Alberico Crespo.Staff writer |

 

June 21, 2017 It started with a letter from US Senator Charles Grassley.

In December 2009, the Iowa Republican demanded to know how a Miami psychiatrist was writing more than 96,000 prescriptions for Medicaid patients. It was nearly twice the number of the second highest prescriber in Florida.

The psychiatrist, Dr. Fernando Mendez-Villamil, responded with a tartly worded message of his own. “I never thought I would be faulted for working hard or for being very organized and efficient,” he wrote the senator.

Health-care fraud costs the US government and insurance companies some $100 billion a year in overcharges and other rip offs, according to experts. It is a perpetual drain on the nation’s wealth, undercutting the ability to provide quality healthcare to those most in need.

Even after Dr. Mendez-Villamil was kicked out of Medicaid and barred from Medicare, he continued to operate an elaborate network of bribes, kickbacks, and payoffs that helped hundreds of fake patients fraudulently obtain Social Security disability payments.

Among hard-boiled fraud investigators in Miami, the strange and circuitous case of Dr. Mendez-Villamil stands out as a monument to criminal innovation, brazen defiance, and greed.

This is the story of how a Miami psychiatrist managed to beat the system year after year, but finally met his match in a health-care fraud investigator named Alberico Crespo.

No one knows the story better than the agent who conducted the investigation and stuck with it through seven years of setbacks and surprises. The story, as told by Agent Crespo, offers an inside look at the problem of health-care fraud from the perspective of an agent on the front lines of that battle.

“He was investigated by a number of agencies who were never able to prove anything,” Crespo said in an interview with the Monitor. “I just happened to be relentless enough.”

Mendez-Villamil was seeing nearly 60 patients every day, six days a week. He allotted 10 to 15 minutes per patient and was writing 2 to 3 prescriptions for each patient. It amounted to 1,400 to 1,500 patients each month.

At that rate, if he billed the standard $45 for each patient visit, he would receive between $63,000 and $67,000 each month under the Medicaid program. On an annual basis that could be as much as $800,000 a year in revenue just from patient visit fees.

Mendez-Villamil was a sole practitioner and employed no other medically trained staff. He retained three workers to help with appointments, handle paperwork, and clean the office. So the overhead expenses for his office were relatively low.

But Crespo couldn’t understand how the psychiatrist was able to see so many people day after day and still do things like eat lunch, use the bathroom, and handle emergency patients.

Through a check of pharmaceutical records, Crespo discovered that the doctor was prescribing large amounts of quetiapine, a drug approved to treat psychiatric patients diagnosed with bipolar disorder. It is sold commercially under the name Seroquel.

According to federal agents, there is a well-established black market in quetiapine, with street names including “jailhouse heroin,” and “Susie Q.”

The prescriptions Mendez-Villamil wrote were paid through Medicaid, so it didn’t cost the patients anything. They could then either use the drugs as prescribed, abuse the drugs, or sell them to others on the street.

“It was a free-for-all,” Crespo says.

See link below to read article in its entirety:

https://www.csmonitor.com/USA/Society/2017/0621/An-epic-case-of-medical-fraud-and-the-agent-who-cracked-it

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