Florida Sanctions Top Medicaid Prescribers, After a Shove

At Dr. Huberto Merayo’s bustling psychiatry practice in Coral Gables, Fla., hundreds of poor patients on Medicaid walked away each year with prescriptions for powerful antipsychotic drugs.

Merayo’s prescriptions for the drugs totaled nearly $2 million in 2009 alone, state records show.

The 59-year-old psychiatrist is also in demand by the makers of these drugs. He’s earned more than $111,000 since 2009 delivering promotional talks for AstraZeneca, Eli Lilly & Co. and Pfizer, according to ProPublica’s database of drug-company payments to doctors.

This year, Florida regulators finally challenged Merayo’s enthusiasm for the pricey drugs, which are used to treat schizophrenia and bipolar disorder. A state review found he hadn’t documented why patients were prescribed the pills and had given them to patients with heart ailments or diabetes despite label warnings.

In May, Florida summarily ended his contract with Medicaid. But the action, though decisive, followed years of high prescribing by Merayo, according Florida’s own statistics. And he was booted only after public questioning by U.S. Sen. Charles Grassley, R-Iowa, who had asked states to investigate such cases.

Merayo’s situation is one of at least three in which Florida allowed physicians to keep treating and prescribing drugs to the poor amid clear signs of possible misconduct.

The state’s responses were marked by head-scratching errors, including the misspelling of Merayo’s name on official documents, and lengthy delays.

In another example, Florida allowed Dr. Joseph M. Hernandez of Lake City to continue prescribing narcotic pain pills to Medicaid patients for more than a year after he was arrested and charged in 2010 for trafficking in them.

States pushed to act

Medicaid programs across the country have long had evidence that physicians have been prescribing risky drugs in excess and perhaps to the wrong patients. These prescriptions also racked up huge bills for the programs.

But like Florida, many states did not act on that evidence. Last year, Grassley demanded data from each state about its highest prescribers of pain pills and antipsychotics, and he asked state and federal officials to determine whether the prescriptions written by these doctors were legitimate.

Since then, states including Louisiana, Arizona, Oklahoma and New York have kicked some high-prescribing physicians out of Medicaid. California has temporarily suspended or placed restrictions on 15 to 20 doctors in the past two years for prescribing disproportionately high volumes of painkillers and antipsychotics to Medicaid patients.

Florida has been in sight lines of law enforcement, politicians and government officials because it is widely viewed as a hotspot for health-care fraud. Until recently, the state’s lax rules allowed pill mills to proliferate, serving as a hub for painkiller distribution in Florida and beyond.

In April 2008, after much debate over the high number of children being prescribed antipsychotics, Florida began requiring doctors to get preapproval before giving the drugs to kids under age 6 in the Medicaid program. Since then, the number of such prescriptions written for kids has plummeted.

But the same level of scrutiny has not extended to prescriptions written for older Medicaid patients.

Florida health officials declined to discuss specific cases or answer detailed questions about why it has taken so long to investigate and sanction some physicians. State officials also would not detail the systems in place to alert them to troubling prescription patterns. The Florida Medicaid program serves about 3.2 million poor children, pregnant women and the disabled.

In a statement, the Florida Agency for Health Care Administration said it “employs a variety of detection tools to determine possible overutilization and other departures from peer group or utilization norms.”

One prescriber, $4.7 million

When psychiatrist Fernando Mendez-Villamil’s role as Florida’s top prescriber of antipsychotics became public in 2009, it made the local news. But documents show Florida had known since at least 2004 that Mendez-Villamil, who also heavily prescribed other drugs, was a problem.

It did not bar him from billing Medicaid until last year after Grassley made his prescribing record public.

Mendez-Villamil wrote more than 96,000 Medicaid prescriptions for mental-health drugs from July 2007 to March 2009, more than any other physician in Florida, according to a list compiled by Florida in June 2009 for Grassley.

Mental-health-drugs typically include antipsychotics, antidepressants and those to reduce anxiety.

In 2009 alone, Mendez-Villamil prescribed about $4.7 million in antipsychotics to Medicaid patients, according to state records.

Florida had been trying to get Mendez-Villamil to cut back his prescribing for years, according to a March 2010 letter from U.S. Health and Human Services Secretary Kathleen Sebelius to Grassley. The total Medicaid paid for all his prescriptions dropped by more than half from 2004 to 2008, she wrote, “Nonetheless the level of activity remains concerning.”

Yet, just months prior to Sebelius’ letter, a Florida Medicaid spokeswoman told The Miami Herald that Mendez-Villamil’s prescriptions didn’t “indicate that there is anything improper.”

Mendez-Villamil, who was officially terminated “without cause,” sued the state last year to have his Medicaid contract reinstated; the case is pending. His lawyer, Robert Pelier, said Mendez-Villamil was “collateral damage” in Grassley’s campaign.

“Dr. Mendez-Villamil doesn’t benefit by prescribing. He doesn’t get paid by the prescription. He doesn’t have any interest in generating [prescriptions] other than medication to keep the patient stable,” Pelier said.

In a 2010 letter to Grassley, Mendez-Villamil wrote that his prescriptions were justified by his busy practice. He worked at least 60 hours a week and saw patients every 10 to 15 minutes, he said. Most required prescriptions for two or three different drugs, he said, and refills made the numbers add up quickly.

Even though doctors aren’t typically paid for prescribing a drug, there are other ways it can be lucrative.

Some doctors require patients to return often for refills, allowing them to bill for office visits. Others dispense drugs in lieu of spending more time with patients, allowing them to squeeze in more appointments. Still others have been arrested or convicted of selling access to their prescription pads.

Top prescriber despite sanctions

Hernandez was Florida’s top Medicaid prescriber for the painkiller oxycodone in 2009. In February 2010, he was charged with trafficking in the pills. He kept his license, however, and continued to rank among the state’s top Medicaid prescribers.

In July, Hernandez’s license was suspended. State officials found that 34 of his Medicaid patients had died — some from drug toxicity — since 2008, according to the state’s suspension order.

Moreover, Hernandez previously had been cited for medical lapses. In 2007, the Florida Department of Health barred him from performing surgery, saying he was legally blind in his left eye. The agency also fined him $5,000 for leaving a hollow needle or a portion of a catheter in a patient’s chest and not telling the patient or the medical staff at the hospital where the patient was transferred. And in 2009, he was fined $1,000 for failing to take a medical recordkeeping course.

Based on Florida’s action, the District of Columbia and Illinois revoked his licenses in 2007 and 2008. Florida then fined Hernandez $10,000 for failing to notify the state about the D.C. revocation.

Shelisha Coleman, a Florida Medicaid spokeswoman, said her agency was not told of Hernandez’s 2010 arrest until this year — even though state investigators were involved in the case. She could not explain why.

Hernandez’s attorney, Gilbert Schaffnit, did not return three calls seeking comment. He told The Miami Herald last summer that his client “is very diligent about the way he practices and prescribes, despite what the state would have you believe.”

Hernandez could not be reached. His criminal court case is pending.

Dumped from speakers’ circuit

In the case of Merayo, ranked second on Grassley’s list of Florida’s high prescribers of mental-health drugs, the state found a variety of problems with his practice.

Some of Merayo’s patients told a reviewer they stopped taking the drugs he prescribed after being granted an exemption from taking the U.S. citizenship test. Immigrants can qualify for citizenship without taking the test if they can prove they are physically or mentally disabled.

A memo from a chief investigator for the Florida Agency for Health Care Administration does not say whether authorities suspect Merayo prescribed the drugs to create evidence of such a disability.

Yet, even when terminating Merayo, Florida had trouble getting it right. The state first informed him that he was being dropped as a Medicaid provider because his license had been suspended — even though it hadn’t been. Merayo’s license remains clean.

The letter also referred to him as “Humberto” Merayo instead of Huberto.

Medicaid subsequently gave a different reason. Merayo was told his Medicaid contract was being terminated “without cause,” something the state can do unilaterally, said his lawyer, Sean Ellsworth.

In a statement provided by Ellsworth, Merayo said he had not been “advised of any allegations involving billing irregularities” by Medicaid. He declined to comment on the allegations in the memo.

Among the companies that paid Merayo as a speaker, Eli Lilly said in an email message that it no longer uses him. AstraZeneca said it doesn’t plan to renew his contract for 2012, and Pfizer did not respond to questions.

ProPublica learned about the terminations of Mendez-Villamil and Merayo from Ken Kramer, a Florida Scientologist who runs a website devoted to exposing what he considers abusive practices by psychiatrists. Scientologists believe that the drugs used by psychiatrists “have no basis in science” and create “lifelong drug addicts,” according to the Church of Scientology website.

Feds walk a “fine line”

Officials at the U.S. Centers for Medicare and Medicaid Services, which works with state Medicaid programs and provides part of their funding, said they don’t keep track of high prescribers terminated by states. Each state administers its own program.

A partnership between states and the federal government, Medicaid provides health care to millions of low-income patients. Some doctors cater almost exclusively to Medicaid patients.

Angela Brice-Smith, director of the agency’s Medicaid integrity program, said her staff is working with some states to ensure the highest prescribers of antipsychotics are using the drugs appropriately, and to educate them if they are not.

“It’s sort of a fine line we’re treading,” she said. “We’re not trying to imply that we’re practicing medicine, but at the same time trying to share our observations.”

High rates of prescriptions do not always mean that physicians are doing something wrong. Some physicians, such as those working in busy urban mental-health centers, may indeed be prescribing properly. Each case needs to be reviewed separately, she said.

Medicaid programs spent more than $27 billion on prescription drugs in 2010, before rebates, according to federal statistics. As state budgets shrink, the pressure on states to “get the bad actors out” is growing, said Matt Salo, executive director of the National Association of Medicaid Directors. “There’s only so much you can do with a slap on the wrist.”

In an email message, Grassley said states need to use their own records to search for trouble.

“High numbers of prescriptions can indicate a busy medical practice with complicated patient needs, or they can indicate a problem,” he said. The government has an obligation to “get to the bottom of anything that looks questionable.”

This post originally appeared at ProPublica.

10 replies »

  1. I think this has broader implications than pill mills. We should be looking for utilization outliers in all areas.


  2. “Why isn’t Grassley hauling these drug company CEOs in to explain to the public why one drug in their company can provide 4 or more billion dollars A YEAR in profits for years at a time?” – DeterminedMD

    Amen. I think the drug companies create an atmosphere conducive to medical wrong doing. Investigations into potential improprieties should not be shoved to the side or ignored.

    I’m not in medicine, I’m actually in media. But, most of my family are doctors or otherwise involved in the medical profession.

    The health of the general public should never be manipulated by those who push particular medicines for various kickbacks.

  3. What is there to explain? Two drug dealers were rightfully sent to jail for drug trafficing and the government used the courts to oppress critics. If you want to argue the public courts have been turned against us I would agree with you all the way. To your claim that treating drug dealing doctors like drug dealers is dracionan isn’t supported by this article at all. I don’t see where there was any claim of system abuse against the doctors just those advocating their cause.

  4. still can’t find the one I remmeber but read these details, how can you say this isn’t trafficing?


    He said he went to the clinic every four months for prescriptions for 120 doses of a narcotic painkiller called Lortab, 90 of Xanax and 120 of Soma, a muscle relaxer. He said the doctor never asked him about symptoms that would require medication. He said he merely told Paulin what drugs he wanted.

    He was given prescriptions for three months of refills. The visit cost $100. Cash.”

    “My source says he visited two other clinics that were similarly solicitous of his needs.”

    Nevadans consume about twice the national average of several prescription painkillers, making us among the most narcotic-addled populations in the United States, according to a Sun analysis by my former colleagues Marshall Allen and Alex Richards.

  5. We should just ignore the doctors who are illegally prescribing mass amounts of drugs then? How do you suggest we combat the illegal trade of prescribed DRUGS without DRUG laws? Their are thousands of doctors out there that will sell you a year supply of pain meds out of the trunk of their car. If thats not drug-trafficing what is?


    “According to the indictment, the three allegedly conspired to distribute highly addictive painkillers, such as oxycodone, hydrocodone, Xanax and Soma, to people without a medical need for the drugs.”

    “Wetselaar and his unlicensed medical assistant, Litwin, allegedly directed their patients — including at least two known drug dealers — to Lam’s Pharmacy at 2202 W. Charleston Blvd., where Smith worked as a licensed pharmacist and pharmacy manager, officials said.”

    “Officials have filed federal charges against 70 people for illegally distributing addictive prescription painkillers since January 2010, Bogden said.”

    “In Clark County alone, the coroner’s office deals with more prescription drug-related deaths than those related to methamphetamine, heroin and cocaine use combined, Bogden said.”

    Maybe in your sheltered world its not a problem but in Vegas, Detroit, AZ, and the cities I know prescription Rx abuse is bigger then your normal street drugs. To say the use of drug trafficing laws is draconian is ignorant of the extent of the problem.

    This case was this year, 2-3 years ago when I was living in vegas full time there was a doctor taken down after a few people died. He didn’t have an office he just made house calls and sold out of his trucnk. That is not a legit medical pratice.

  6. Hmm…I suspect ProPublica is getting itself into a complex medical situation again without paying much attention to the longstanding and mostly incorrect draconian use of drug-trafficking laws against doctors. If this doctor is one of the few offering to help people with chronic pain it’s not too surprising he prescribes a lot of pain killers. Most doctors wont because of the insane actions of the DOJ over the years, and so most chronic pain goes untreated in this country–and even the first Bush Administration reported on that. Plenty of evidence about that on THCB over the years.

    But instead of looking into that problem (try looking into the story of Siobhan Reynolds incredible treatment by the Grand Jury), ProPublica is following up on the oh so robust scientific judgement of the church of scientology.

    I dont like to meddle in the editorial affairs of THCB but I think our time running ProPublica’s health stories here is coming to a close………..

  7. Florida? Problems with pill mills and medical practice???
    Surely not.
    I’m shocked.
    Why, they just elected a former medical pro as governor. Oh, wait…

  8. Not sure how valid this is?

    “New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.”

    States have been shutting mental health facilities and turning the patients out on the street for a long time now, then using the jails as the new treatment centers. I guess that’s the new approach to making everybody richer by cutting costs.

    What needs to be asked is are drugs being used by the poor because it’s the only way they can afford any kind of treatment for mental illness? Drugs are also being used as chemical restraints in old age homes where staff levels are low.

  9. So who is the villain here, especially when it comes to expensive medications like antipsychotics? The doctors who write the prescriptions, albeit in the numbers cited above does sound like they were written like they were pez, but, what about companies like Astra Zeneca or Bristol Myers who are trying to get further indications for their drugs Seoquel or Abilify, respectively, charging $10-20 a pill for them? Why isn’t Grassley hauling these drug company CEOs in to explain to the public why one drug in their company can provide 4 or more billion dollars A YEAR in profits for years at a time?

    At the end of the day, if you are honest and appropriate as a physician, you won’t get attention of the state or feds. Just ask yourself, why are you seeing 30 or more people a day and billing for more than $300 thousand a year and expecting that reimbursement from MA or MC as primary insurance payors? Wouldn’t it be easier just to put a neon sign on your window or exterior of the building saying “Better living through chemistry sold here!”