At the request of Mr. Cannick, for the defense, Nina Carosella, fraud investigator for Medicare, read this letter to the court. The letter was faxed from Ms. Carosella’s office to the federal building during proceedings today.

The letter is from Dr. Dhafir to Barbara Barton, R.N., Case Analyst at the Medical Review Department. The letter is written on Dr. Dhafir’s letterhead, Madison County Medical Care, P.C. As a direct consequence of this letter, Dr. Dhafir was put on a prepayment flag which meant that Medicare would check all his billing before any payment was made. The letter is dated September 23, 1993.

Re: Reply to letter of September 3, 1993

Dear Ms. Barton:

Thank you for your letter of September 3, 1993, in which you outlined some but not all of our conversation in the meeting we had on August 13, 1993.

The things that you pointed out in your letter that I would like to clarify are as follows:

1) We did not do any incorrect billing; our billing was done correctly as far as we are concerned. It is your inconsistencies and changes in policy that are making our lives very difficult, and it is confusing to our staff trying to keep up with your constant policy changes. It was clear at the meeting that even you do not agree with, or even understand, given issues in the same way. This was clearly demonstrated when the issue of Lupron arose, whether it is to be considered a chemotherapy injection. Some of you said that it was not, and others said that it was, and finally you mentioned that Lupron is indeed considered a chemotherapy agent, and should be billed as such when it is administered, and this is the way we will continue to bill for this service.

2) We made it very clear to you by telephone, in writing, as well as verbally myself during the meeting, that we are billing for services and supplies which we are well aware you are not going to pay; this is done simply so that we can pass it on to the secondary insurances for proper payment. It is beyond me why you continue to bring us this issue in our conversations, as if it were an intentional error on our part, and we have made it clear to you as to what this issue is, and I am very annoyed on top of all this at your statements made in the letter of September 15, 1993, a copy of which is enclosed. If you remember, we requested a form letter, not addressed to anyone in particular, but a generic statement in which you indicate what items you will not reimburse, so that we can use it for billing the secondary insurances. Unfortunately, your letter of September 15 produced no such thing; all it produced was more threats and unfounded accusations. The format that was done is of absolutely no value to us. Until we receive a clear statement from you, as we agreed in our meeting, we will continue to do our current billing.

3) I disagree with you as to item number 4, in which you allege that there is a discrepancy in the drug dosage on the same chart. Everything that we do has been done correctly, and there was only one incident which I explained to you, along with surrounding circumstances, and you were satisfied. Again, it is beyond me why you keep bringing it up as if it was a chronic problem in our office. I wish in the future you would be more careful making generalized statements like that.

4) As far as the billing for the local anesthesia for bone marrow and billing for the laboratory panels, it was made very clear to you that your changes in policy are making our lives intolerable. We are expected to keep up with all of your changes. We work in more than one office, and sometimes it is difficult passing on all of the information to all of our offices, specifically in regard to your panels, which are changing every few months. Or lab technician has not been able to keep track of your policy changes, and I wish you would stick to one panel and not change all the time.

5) As for the issue of the level of billing, I could not agree with you more. Indeed, our billing level has not been consistent with the code that we submit, simply because we always do more than what we are billing for. We always undercode simply because of the intimidation factor from your office. You seem to forget that the vast majority of my patients are cancer patients, and I cannot envision any situation in which one of these patients would walk in and out without being seen by the doctor and provided with care for less than thirty minutes at minimum. Even with that, more often than not, we charge at level 3, which you are aware is below what we should be charging. This was brought up to you at our meeting, and everybody in the room agreed with me when I made the statement that I have lost, and continue to lose, hundreds and thousands of dollars because of this.

6) As far as x-ray billings are concerned, they were all correct, and I wish you would not make blank statements like you did in item 10, when the information you requested was given to you and you were satisfied with it. Everything we did was well-documented.

7) I hope that you will remember the statements that I have made and emphasized to Dr. Harding and all those present that neither I nor my staff appreciate any threatening letters, phone calls or communications in any form, such as the almost entire page four of your letter, as well as the follow-up letter of September 15, 1993. Indeed, this is not a civilized way of dealing with people, and my staff and I resent this to the highest level. I wish you would refrain from using these threatening statements in your communications with us in the future.

You are well aware that we are going out of our way to try to comply with your ever-changing, ever-unreasonable, ever-underpaying rules and regulations. Our offices pride themselves on providing excellent care for our patient population with all honesty, and any innuendoes to the contrary, whether by you or anyone else, will not be unchallenged.

8) As far as billing for hydration only in our office without chemotherapy, this will be billed at level 5 plus per hour charge plus IV solutions and supplies. This should not be mixed up with the hydration given during chemotherapy.

Please find enclosed a check that you requested for a refund of $887.20, which I don’t necessarily agree that you are entitled to, when we consider the hundreds of thousands of dollars that this practice has been deprived of because of all your rules and regulations, and because of your failures to notify our offices for our under-charging for the last ten years.

By cashing this check, we assume that you agree with the content of this letter, unless we hear from you otherwise.

I hope we can have a better relationship than the one that is reflected in your letter, and I look forward to receiving the denial form that we requested as soon as possible.

Rafil A. Dhafir, M.D.
President, Madison County Medical Care.