Sunday, August 24, 1986
Medicaid fraud doesn't stop these docs
Many Medicaid Violators Continue To Practice Medicine
By Edward Colimore and Howard Goodman, Inquirer Staff Writers
Dr. Arnold Lincow and his clinic did hundreds of thousands of dollars in business with Medicaid patients in Philadelphia - and then state officials said they wouldn't pay him any more.
He broke Medicaid regulations, they said, by performing 145 unnecessary treatments on welfare clients.
But that didn't stop Lincow from billing for thousands more dollars, the attorney general's office said. After Lincow got word of his expulsion, the state said, he submitted 961 more invoices to Medicaid by fraudulently using the names of other physicians - including one doctor who was in his last, dying month, hospitalized with a heart attack.
Lincow was indicted in 1982. The following year, he pleaded guilty to 10 counts of Medicaid fraud, and was placed on probation and fined. In 1985, his license was suspended - for 90 days.
Today, Dr. Lincow is again practicing in Philadelphia, and the federal government is still seeking $418,402 from him in fines and restitution.
He is not the only Pennsylvania doctor who continues to practice on an unwitting public despite being convicted of crimes against Medicaid. An examination of records reveals that there are scores of such doctors.
And there are scores of others who continue to practice despite being barred from Medicaid because their medical practices and techniques have violated state regulations.
The state Department of Public Welfare is dropping such doctors in record numbers from Medicaid, the mammoth state and federal health-care program for the poor. Tighter regulations and stepped-up enforcement have created a dramatic increase in doctors cited for Medicaid abuses.
Overall, according to state records and interviews with medical investigators, doctors, through improper billing, stole about $13 million from Pennsylvania taxpayers last year alone.
But only rarely do the state's licensing boards, which are supposed to protect the public from violations of medical and ethical standards, follow up by significantly limiting those doctors' right to practice.
State records show that 34 doctors who are currently barred from the Medicaid program - and who also have been convicted on criminal charges - are still permitted to practice medicine in Pennsylvania. Most of those are in Philadelphia. In addition to Lincow, the list includes:
* Dr. William I. Schwartz and Dr. Mitchell Schwartzman, osteopaths and partners, who pleaded guilty in 1982 to conspiracy charges. A grand jury said that in one instance, they examined 24 residents of a West Philadelphia boarding house on a single afternoon and diagnosed every one of them as suffering from either laryngitis or vocal cord spasm.
* Dr. Jay Freifelder, a North Philadelphia podiatrist who pleaded no contest to one charge of billing Medicaid for a nail excision never performed. In a plea bargain, he paid $615 restitution on another 22 counts for abscess drainage, X-rays and other services allegedly not performed.
* Dr. Steven Saffren, a North Philadelphia dentist who received seven years' probation from the courts stemming from charges that he billed Medicaid for denture work, restorations and other procedures on 28 patients who received only part of the work claimed, or none at all, according to investigators who examined their mouths.
Schwartz and Schwartzman had their licenses suspended for 90 days by the state licensing board that supervises osteopaths. Freifelder had his license suspended by the podiatric board for 90 days, followed by a three-month probation. The dentistry board stripped Saffren of his license for six months. All four are now practicing again.
There is another group of practicing doctors who have not been convicted of fraud charges but whose methods have been found to be in violation of state Medicaid regulations - such as Dr. Felix Spector of North Philadelphia. Officials said he wrote hundreds of prescriptions for potentially addictive drugs, while not obeying a regulation to record why the prescriptions were needed. Officials said that he also billed the state for seeing patients who were actually seen by other doctors, that he falsified pharmacy records, and that he performed a surgery - a castration - "of grossly inferior quality," in his office on an outpatient basis.
The licensing boards imposed no discipline on Spector, an osteopath. Nor did the boards discipline five other doctors in Spector's clinic who were found in violation of state regulations for infractions ranging from ordering hundreds of unnecessary diagnostic tests to issuing 374 prescriptions for Valium in a single month without documenting why.
At present, 142 physicians, dentists, chiropractors, podiatrists and optometrists are barred from the Medicaid program for various violations of state regulations, according to lists distributed monthly by the Department of Public Welfare.
Of those 142, Department of State records show that state licensing boards have taken no action against 88, meaning their practices could continue without interruption. Twenty others had their licenses revoked; three of them later got their licenses back. Twenty-four had their licenses suspended, mostly for 90 days. Nine others were put on probation while allowed to continue practicing. One more got only a reprimand.
The Medical Practice Act of 1974 gives the State Board of Medicine the power to refuse, revoke or suspend physicians' licenses for people who have been convicted of a felony in any state, or who are "guilty of immoral or unprofessional conduct."
"Unprofessional conduct," the statute reads, "shall include any departure from, or the failure to conform to, the standards of acceptable and prevailing medical practice, in which proceeding actual injury to a patient need not be established."
But that board, and those regulating osteopathy, dentistry and other health professions, do not often discipline doctors who have been convicted of fraud or whose practices have been cited as unprofessional by the Department of Public Welfare.
"The boards have been very unreceptive in Medicaid fraud cases - they represent only money," said Robert Gentzel, spokesman for the state attorney general's office. "The boards tend to be most responsive when you show that harm has been done to a patient - someone is really sick and the doctor does harm to him approaching malpractice."
Barbara Shore, chairman of the State Board of Medicine, which authorizes licensing of medical doctors, said that the boards investigate every complaint they receive, but that cases in which lives are endangered take priority. Records show that the board last year took disciplinary actions - ranging from a reprimand to the revocation of a license - in one out of every four complaints.
"There is a difference," says Nancy Matlowski, chief prosecutor for the licensing boards, "between the termination of a contract and the termination of a professional livelihood. There is no provision in the statutes that termination from Medicaid should result in the revocation in someone's license."
Records provided by the attorney general's office show that boards, when deciding to review a doctor's case, have taken years to hold hearings and finally reach their decisions. During all that time, the doctor is free to continue practicing. The boards will not reveal the identity of doctors whose cases are under review.
The public is generally left unaware of a doctor's background, even if he has been convicted. Nearly half of all doctors expelled from Medicaid are from the Philadelphia area. Most of them continue to advertise their practices, treating new patients who do not know about their pasts.
Carolyn Holmes, president of the Health Federation of Philadelphia, a nonprofit organization composed of officials of federally funded city health centers, said the overall lack of information makes it difficult for the public to choose doctors.
"A physician's office is a business," she said. "The Better Business Bureau and the credit bureau can give ratings on other businesses, but a doctor's office is isolated from that. So, where do you go?"
Medicaid, for the most part, is a massive honor system.
Patients on welfare, carrying Medical Assistance cards, can go to any of the hundreds of doctors registered with Medicaid. With some exceptions, the patients simply sign invoices for medical services approved by the government. The doctors send the invoices to the government for reimbursement. Medicaid sets the fees - too low, many doctors say.
The invoices flow into Harrisburg at the rate of 100,000 a day. And in most cases, reimbursement is automatic - Medicaid in Pennsylvania paid out more than $433 million last year for outpatient care.
With so many invoices, it is not possible, state officials say, to double- check more than a small portion of the claims. For most billings, state officials say, no one double-checks whether doctors actually performed the services they claimed, or if the doctors provided services that patients truly needed.
According to some health providers who have been convicted of Medicaid fraud, their crimes are a blend of greed and opportunity.
Alan R. Lieberman, a Bryn Mawr businessman who operated three medical facilities in Philadelphia, pleaded guilty to submitting 14,000 false claims to Medicaid between 1977 and 1980. He agreed to pay $1.37 million in restitution and went to federal prison.
At his sentencing, Lieberman said he committed the fraud while ''associating with doctors who look more for gain than they do to heal."
Another defendant in the case, Jonathan A. Lipner, a Lafayette Hill man who worked for Lieberman, pleaded guilty to paying kickbacks to physicians in exchange for medical test referrals for a laboratory he co-owned with Lieberman.
"I was like a kid in a toy store," Lipner said during his sentencing. ''It looked like candy, and I knew I did the wrong thing, and it wasn't an easy thing to wash my hands of, but it's a thing that sort of snowballed."
But in the last several years, the state has become increasingly active in policing the system.
Lately, doctors are getting caught.
With a computer to spot unusual billings, and with a bureau of the Welfare Department investigating for faulty medical practices, Pennsylvania has established a pace for rooting out substandard or cheating doctors which, officials say, few other states can match.
Since 1980, the Department of Public Welfare has expelled more than 600 ''health providers" - a phrase that includes doctors, pharmacists, medical center owners, even shoe stores that sell corrective shoes - for various violations of Medicaid rules. Most of the expulsions lasted three to five years. Many of the providers then renewed their participation in the Medicaid system.
About half of the expelled providers were convicted of crimes, usually for fraud or for breaking federal drug laws. The other half were expelled for sloppy or dangerous medical practices.
These include doctors who issued unjustified prescriptions, performed unacceptable surgeries and required patients to return time and again when they weren't sick.
In the bland language of the Welfare Department's watchdog agency for Medicaid, these doctors failed to meet "acceptable and customary standards of medical practice."
The agency, known as the Bureau of Utilization Review, employs teams of nurses, pharmacists and doctors to comb medical centers and patient records to make sure that Medicaid patients' care is up to standards.
The agency has found medical records written so negligently that investigators cannot even tell what the patient was supposed to have been treated for. It has found notations ordering large numbers of medical tests - without any record of what the patient was complaining of, or even whether there was any suspected illness.
It found a North Philadelphia general practitioner, Dr. Eduardio Paez, who, investigators said, ordered a 34-year-old woman with a suspected drug habit to visit his office 31 times over three months in 1981. Paez continually prescribed addictive drugs for the woman, investigators said, despite knowing her problem. Although expelled from Medicaid, Paez is still licensed in Pennsylvania. Efforts to reach him for comment were unsuccessful.
It found a North Philadelphia physician, Dr. Martin Munoz, who claimed he performed 116 cauteries of the cervix over three months in 1981, the state said - an extraordinary number for a relatively rare procedure. Investigators tracked down 21 of the patients - and 19 said they never had the procedure. Munoz's Pennsylvania medical license later expired, and officials said he apparently moved to Colombia.
And the Welfare Department found others.
BILLINGS AND FRAUD
Arnold Lincow started as a science teacher in the Philadelphia school system, a "truly caring teacher," a colleague said. Lincow also was a pharmacist and put himself through medical school.
To his clientele, he showed a commitment, said City Councilman John F. White Jr., of "providing the health care for people who sometimes can't afford it."
He was dedicated, said John F. White Sr., an assistant managing director for the city, to improving the decaying West Oak Lane neighborhood where he practiced.
Patients liked him. Elaine Johnson visited his office frequently for chronic headaches. Curtis Ackridge saw him for high blood pressure and neck and shoulder pain. Both had only good things to say about Dr. Lincow.
"The first time I met him, it was like I already knew him awhile," Johnson said in an interview. "He was a good doctor."
Both Medicaid patients left Lincow's office at 7622 Ogontz Ave. with prescriptions for painkilling drugs.
What they didn't know, and what state investigators would later find, was that Lincow billed Medicaid for trigger-point injections - a treatment involving the use of a needle to inject muscle-relaxing drugs directly into a muscle.
"I would have remembered something like that," said Johnson, 32, of the 5600 block of North 16th Street. "I didn't get any needles."
"I got vitamin shots," said Ackridge, of the 2200 block of North Franklin Street. "But I never got needles anywhere other than my arm. I know that."
Lincow eventually would be charged in state court with 961 counts of Medicaid fraud and would plead guilty to 10 counts. Investigators would say he used the names of three doctors he employed to illegally collect Medicaid payments for his clinic - including one who was in a hospital, dying of a heart attack. And the federal government would seek $418,402 from him in fines and restitution.
Lincow is still practicing in Philadelphia.
The cases against him started when the state Welfare Department declared that in 1979 and 1980, Lincow had performed 145 "not medically necessary" trigger-point injections or arthrocentesis, a treatment involving the use of needles to withdraw fluid from joints.
The state expelled Lincow from Medicaid in October 1981 for three years. The welfare department said that Lincow's failure to document medical necessity for the injections and several kinds of diagnostic tests was ''contrary to acceptable or customary standards of good medical practice."
But Lincow, whose clinic had amassed $278,427 in Medicaid billings in 1979 alone, did not let his impending removal from the program stop him from billing Medicaid.
With the deadline for his expulsion approaching, Lincow called a staff meeting and outlined a strategy for staying in business, according to his former clinic administrator. The administrator, Jerome Esterson, told the story to a state attorney general's investigator, who recounted it in a criminal complaint.
The strategy, Esterson said, was to hire doctors with valid Medicaid provider numbers - and to use their names and provider numbers instead of Lincow's.
Lincow said he wanted doctors "who made money for him, who ordered tests and made the recipients come back," according to Esterson.
Esterson said Lincow instructed the staff to order many laboratory tests, ''to feed the pharmacy" with prescriptions, and to write the initials ''R.T.C." on Medicaid patients' files. The initials meant "return to clinic" for more visits.
"The philosophy was to 'treat them and street them,' " said Thomas E. Herrmann, an attorney for the Inspector General Division of the federal Department of Health and Human Services. Herrmann made the statement in May at a federal administrative hearing on Lincow.
According to the criminal complaint, Dr. Stanley Boos, an osteopath in Lincow's employ, told investigators that Lincow wrote phony procedures, prescriptions and office visits into Boos' records on patients.
Dr. Robert Trollinger, another physician working for Lincow, said Lincow used Trollinger's provider number to bill Medicaid for seeing patients, the complaint said - though Trollinger never saw the patients or gave Lincow permission to use his number.
And, the complaint alleged, Lincow's Frankford Medical Center at 2940 Frankford Ave. in Philadelphia submitted 703 bills - totaling $6,893 - to Medicaid in the name of Dr. Anthony Scardino, an osteopath working for Lincow, between July 24 through Aug. 18, 1981.
But Scardino suffered a heart attack on July 24. For two weeks he was a patient at the Cherry Hill Hospital in New Jersey. Then he went home - only to suffer a second attack. He died on Aug. 18.
Attorney Kenneth E. Aaron defended Lincow in letters to Health and Human Services officials and a federal administrative law judge by saying that Scardino had directed the preparation of the claims in his name. All services, Aaron added, had been performed by a lawful provider.
The Commonwealth of Pennsylvania, basing its case on the complaint, charged Lincow with 961 counts of Medicaid fraud in 1982. Lincow pleaded guilty to 10 counts - paying $25,000 restitution, $10,000 in court costs and $5,000 in fines.
The State Board of Osteopathic Medical Examiners suspended Lincow's license for 90 days beginning in December 1984. The doctor did 300 hours of volunteer medical work.
Lincow refused to comment on his case on his attorney's advice. But in a hearing before the osteopathic board in 1984, he maintained that he never billed for unneeded or undelivered services. He blamed Esterson for the apparent irregularities in the clinic's billings, saying Esterson had personal motives for making charges against him.
"My conscience is clear concerning my duty to keep my sworn promise as a physician," Lincow said, adding he hadn't known it was illegal to bill the state for a service rendered by another physician. Still, he said: "I am captain of the ship, and I take responsibility."
Meanwhile the case goes on.
The federal Department of Health and Human Services is demanding that Lincow pay an additional $363,766 in fines and restitution for allegedly cheating Medicaid, in charges that are roughly the same as the state's were. In addition, the federal department wants another $54,636 from Lincow for allegedly bilking Medicare, the national health plan for the elderly, after his Medicaid convictions.
The Philadelphia County grand jury couldn't believe it.
Dr. William I. Schwartz and Dr. Mitchell A. Schwartzman claimed that in a single day, they visited 24 residents of a West Philadelphia boarding home and gave each of them a "direct laryngoscopy."
That is an examination of the vocal cords that, the grand jury was told, requires patients to be sedated and usually anesthetized while an instrument is inserted into the windpipe. The procedure is normally performed in an operating room.
The doctors had reported that nine of the boarding home residents had laryngitis and that the other 15 had laryngospasm, a spasm of the muscles affecting the vocal cords. Laryngospasm, the grand jury was told, is usually regarded as a medical emergency.
The grand jury cited the incident as it indicted the two osteopaths for conducting hundreds of needless medical tests over a two-year period and for billing Medicaid for thousands of dollars in work that was never performed.
"We find it incredible that 24 patients in a single boarding home on the same day would be afflicted with either laryngitis or laryngospasm," the grand jury said.
The doctors pleaded guilty to charges of conspiracy to commit theft and securing the execution of documents by deception.
Schwartz and Schwartzman were sentenced in July 1982 to four years' probation and fined $12,000 and $15,000 respectively. In exchange for their negotiated pleas, each was ordered to perform 1,000 hours of community service for the city's Health Department.
In addition, each was ordered to repay $11,250 to the Department of Public Welfare and to pay $5,000 for the costs of prosecution. According to state records, both doctors also were suspended from Medicaid - Schwartz until July 1986, Schwartzman until December 1987.
Both lost their licenses for three months in 1983. Today, the 35-year-old doctors are back practicing in Philadelphia.
The two were high-school acquaintances who graduated in 1976 from the Philadelphia College of Osteopathic Medicine and went into partnership.
They said in interviews that they started in practice in the inner-city because that looked like a way to become established without committing themselves to a big financial investment. Their first full year following internship was 1978; they took in $233,000 in Medicaid payments for services and X-rays.
That year, a grand jury said, Schwartz and Schwartzman billed Medicaid for 1,805 ventilation studies, or breathing tests, in their cubicle office behind a drug store on Lancaster Avenue. They did more tests than Presbyterian- University of Pennsylvania Medical Center, which specializes in the procedure, and the Hospital of the University of Pennsylvania combined.
"It is clear to us that Drs. Schwartz and Schwartzman were paid at least $8,670 on the basis of false and misleading statements purporting to justify their billings for these studies," the grand jury said, "and that the studies could not and did not confer any benefit on the patients on whom they were performed, but served to benefit only the makers of these statements."
The grand jury was convened three months after Schwartz and Schwartzman were publicized in a 1978 Philadelphia Daily News series that said Schwartz had given Valium and Elavil pills to a reporter posing as a welfare patient.
The grand jury's report, issued in 1980, ran 57 pages.
Joseph Casey, an assistant district attorney who outlined the government's case at the doctors' sentencing, said in court that "junkies" who had ''track marks up and down their arms" got drug prescriptions they wanted from Schwartz and Schwartzman - but only after agreeing to X-rays, which they didn't want or need.
The doctors' X-ray machine was so dated, Casey said, that their technician, Pat Mosely, "had heard legends about such a machine but didn't think any were in existence. She thought they were all in the Smithsonian."
And though the machine took unusable pictures, Casey said, the doctors billed Medicaid for them anyway.
The doctors said in interviews that all the medical services they rendered had been performed in good faith. They blamed their legal troubles on overzealous prosecutors. "A witch hunt," Schwartzman said.
They said they pleaded guilty because it was getting too expensive to pursue the cases and because their lawyers advised them that juries would be unsympathetic.
The doctors said they are glad to be rid of the "fear and specter" of the Medicaid bureaucracy, which they described as eager to pounce on physicians for minor reasons. Their current patients are unaware of their convictions, they said.
"I've been involved in a good, solid practice for eight years," Schwartz said.
"I went through a couple of years of hell," Schwartzman said. "Now I'm a pretty happy guy. I practice medicine. My patients like me."
TOO MANY DRUGS
Joanne Robinson always felt sick. She weighed too much at 230 pounds. She'd had heart trouble since she was a girl. So she went to Dr. Felix Spector, whose clinic in her North Philadelphia neighborhood was well-known.
That was in 1975. Robinson was 31, rearing her eight children in one of the few inhabited rowhouses in a line of ravaged buildings on the 1700 block of North 16th Street.
She coped with a host of ailments besides her heart murmur: chronic high blood pressure, arthritis, an assortment of allergies, a tendency to retain fluids, a hernia, depression so severe that she was twice hospitalized.
Spector had a kindly manner, she recalled, and he had a formula for her problems: She should lose weight.
He put her on methamphetamine and Dexedrine and Statobex - green and white speckled tablets that act like amphetamines, Robinson said in an interview.
Robinson's medical chart, covering four years of visits to Spector's clinic, shows prescriptions for those drugs - and for at least 33 other medicines designed to combat a wide variety of ailments. The chart shows that Robinson was prescribed drugs on 187 trips to the clinic from March 1979 through March 1983.
State records of Medicaid billings show that taxpayers paid for 1,265 tablets and capsules for Robinson in one four-month period in 1978. Taxpayers bought 2,450 tablets and capsules for Robinson in the last four months of 1979, the records show.
But the charts show that Spector rarely recorded why Robinson needed the drugs - a violation, investigators later said, of Medicaid regulations.
All the while, Spector was making money, courtesy of taxpayers.
Medicaid records show that in 1981 alone, Spector, along with six other doctors and a dentist in his clinic, collected $362,000 in Medicaid payments. And the clinic pharmacy took in $400,000 more from Medicaid.
Then, in 1982, state investigators took a look at the doctor - with Robinson providing the Bureau of Utilization Review with key information about the doctor. Investigators found Robinson's situation was not unique. Checking Spector's records for a random 100 patients, they found that he prescribed potentially addictive drugs on 412 occasions without documenting the reason in patient records, in violation of Medicaid regulations.
By 1984, the Welfare Department refused to let Spector or five other of the clinic's doctors participate in any further Medicaid business. But Medicaid billings continued to be sent from the clinic, and, in January, the department banned the facility's entire staff from Medicaid.
Nonetheless, Spector is still practicing in the North Philadelphia clinic, and most of the other doctors still practice in other parts of the city.
Robinson said she began taking the amphetamines on a Friday in 1976. She said the pills kept her from sleeping for three nights. Then, starting that Monday, she fell asleep and did not wake until Wednesday.
That frightened her, and for two weeks she stayed away from the pills. But Spector insisted that the amphetamines were important, she said, and she began taking them again.
Robinson took amphetamines every day for four months, she said, and her weight dropped from 230 to 167 pounds.
But her mood changed noticeably as well. She grew picky and sullen. Then amiable.
"I flew back and forth so fast, I scared my own self," Robinson said. She had explosive, irrational fights with her husband, Larry Smith. She retreated into silences. She could not stop moving.
"It was nothing for me to get up in the morning, walk down to Center City, just walk around, turn around and come back home," she said. "My heart would be thumping, and I would be sweating, but I just couldn't stay still.
"And then it got to the place, I'd be standing in the back door, and to keep from being still I'd just stand and jog in place."
She said that to slow her down, Spector prescribed Valium, four doses a day. The doctor also ordered Elavil, an anti-depressant. State medical investigators say it can cause abnormally high heartbeats in large doses.
And to ease strain on her heart, which she said was sprinting under the amphetamines' demands, Robinson took Nitrobid, time-release capsules containing nitroglycerin to improve blood circulation. State records show that Spector billed Medicaid for 360 capsules of Nitrobid for Robinson between May and July of 1978 alone.
She said she took Motrin and Talwin for arthritis pain, Lasix to reduce body fluids. State records show that Spector billed Medicaid for 500 capsules of the pain reliever Fiorinal with codeine for Robinson between May and August of 1978.
In the decaying rowhouse home that Robinson's family rented, drugs became the one possession in abundance. There were so many pills and tablets, she says, that she eventually bought a Physicians' Desk Reference, the authoritative drug handbook, to read about the drugs.
"She came home with a lot of pills," Larry Smith said, "a whole bag full, all kinds . . . I would joke with her - I used to call her a pill factory."
Robinson said that the pills eventually filled two shopping bags. And seven Robinson children who saw Spector got enough pills to fill a shopping bag of their own, she said.
Her daughter's medical charts show that the 14-year-old was given a narcotic pain-reliever usually considered too dangerous for children.
After her 13-year-old son bumped his head on the household stairs, he was given anti-anxiety pills, his record shows - pills that are usually used in psychiatry. He took two of the pills, and the family was so alarmed at his reaction - he fell down repeatedly, giggling - that they called the police, Robinson said.
One weekend, on a trip to a family barbecue in Newark, N.J., Robinson was clutching 12 envelopes of pills and her mood was growing bad.
"And all of a sudden, I'd say 4 o'clock, I began to feel very jittery, and it felt like I was very nervous, like something was crawling up under my skin. . . .
"Finally, I was sitting on the porch," Robinson said. "It seemed like everything was closing in on me . . . All of the sudden I looked at Larry's brother, Keith, and said I needed help."
Robinson had bloated grotesquely, her face puffed, her fingers so swollen that her skin seemed to have swallowed the ring she was wearing. On the ride to the hospital, Robinson leaned upright against the back seat of the car. She could not bend into a sitting position.
In the emergency room, a doctor asked her if she had been taking any medicines. "I had the pocketbook and I just threw it at him," she recalls. ''When the pills started falling out, he said, 'Oh, Lord.' "
A Newark Beth Israel Hospital record of the emergency on May 29, 1976, shows that Robinson was given an injection of Thorazine to counter what doctors diagnosed as an amphetamine drug reaction.
Robinson said that a doctor told her sister-in-law it had been a close call. "They said if I had laid down or sat down I would have died," Robinson said.
Her hospital record shows that doctors determined that Robinson had taken heavy doses of Talwin, Elavil and possibly Statobex, as well as a diuretic known as HydroDIURIL. Dr. Leonard N. Horowitz, a cardiologist at Hahnemann University Hospital who inspected the record for The Inquirer, said that a diuretic and amphetamines taken together can combine to create harmful, abnormal heart rhythms.
In an interview, Spector denied giving Robinson many amphetamines.
"She never had that much," Spector said. He insisted that Robinson never got ill from amphetamine usage.
"She was taking other things," Spector said. "She insisted she had this, or had that. She had a lot of other complaints. She required lots of difficult care - hypochondria and hypertension - common in that kind of neighborhood."
Spector acknowledged that he prescribed amphetamines for weight loss, but said that state investigators exaggerated the amount of amphetamines he prescribed. He added that the diets rarely were effective.
"They all failed about the same," Spector said. "Some patients took it for a week or two. Others stuck it out for five or six weeks. They weren't a very compliant bunch."
Robinson said Spector gave her an explanation for her emergency. "He told me it wasn't the medicines, basically, it was the combination of the sauces and stuff I ate, that spices activate certain medicines."
Postscript: Robinson eventually weaned herself from the amphetamines. She said she guided her use of medications by reading the Physicians' Desk Reference she kept at home. In 1983 she began cooperating with the Bureau of Utilization Review in its examination of Spector's clinic. Spector soon dropped her as a patient.
Dr. Ashley Botnick was a dentist with something sweet to offer. Any patient who came in for a six-month or yearly checkup could win $100 cash or a Sony Walkman AM-FM radio. He called it the "Check-Up Sweepstakes."
That was the 1984 contest. The year before, Botnick's office at the Broad & Olney Medical Center, 5602 N. Broad St., had offered a sweepstakes boasting a $250 grand prize, two $50 second prizes and a radio for a third prize.
All anyone needed for a chance was a checkup.
State officials say the contests violate state Medicaid regulations, which prohibit rebates, kickbacks and inducements for doctors' services. Medicaid officials say the practices encourage unnecessary and costly medical attention.
John Ferrara became eligible to win when he made an appointment to see Botnick on May 29, 1984.
Ferrara, a registered pharmacist, is director of outpatient services for the Bureau of Utilization Review. He was posing as a Medicaid patient - just another day's work.
Since 1980, investigators for the Welfare Department have gone on more than 100 undercover assignments, pretending to have minor medical complaints to see first-hand how Medicaid recipients are treated.
Ferrara has been poked and prodded. He's had his blood drawn and his feet fitted for unnecessary orthopedic shoes.
In Botnick's dental chair, he had his gums cut with drill instruments by an unlicensed hygienist who was cleaning his teeth.
At one point, Ferrara said, the hygienist dropped the drill's polishing attachment on the back of his tongue. Ferrara could have choked.
He said that when the drill piece fell in his mouth, the hygienist warned: ''Don't move. I'm trying to get it."
Botnick billed Medicaid for the dental work. After a second undercover investigator was treated by an unlicensed hygienist, the state dropped Botnick
from Medicaid on March 2, 1985. He won't be eligible again until Aug. 15, 1988.
Botnick refused to comment on the state actions. He continues to practice, part of the time at the Ogontz Dental Center in North Philadelphia. And he still believes in advertising.
A sign on the building reads: "Be True To Your Teeth Or They'll Be False To You."
Ferrara called himself Frank Powell when he went to see Dr. James Barnes, a medical doctor, at the Columbia Clinic in North Philadelphia.
An associate, Debra Hoy, called herself Mary Barrett.
Both were perfectly healthy. A doctor had checked them the day before.
Hoy saw Barnes first. She told him she had a headache.
The physician responded by examining her throat with a device called a larynxvue. He laid it on the back of her tongue. "I wondered why he looked down my throat," Hoy said later, "when I complained of a headache."
Barnes told her: "We like to have these tests done on all new patients."
According to a report that Hoy filed of the 1981 visit, Barnes ordered four sinus X-rays, two chest X-rays, a urine sample, two electrocardiograms, and a lung capacity test that involves blowing into a tube. An assistant drew five vials of blood for lab tests.
Ferrara was next. He complained of an earache. Barnes ordered two chest X- rays, a lung capacity test and two electrocardiograms. He examined Ferrara's throat with the larynxvue, and had an assistant draw five vials of blood.
Ferrara said Barnes stuck an unsterilized thermometer in his mouth.
"The thermometer was laying on counter," Ferrara said.
Hoy and Ferrara walked away with prescriptions for penicillin, an antihistamine, a decongestant, and other drugs.
According to Medicaid computer records, Barnes billed Medicaid $510 for the
examinations, X-rays and lab tests. That included billing for two electrocardiograms with exercise - more expensive tests than the electrocardiogra ms he actually gave, with the subjects at rest, Ferrara and Hoy said.
Barnes "failed to adhere to the standards of practice on all six diagnostic services," the welfare department concluded - and suspended him
from Medicaid for five years.
The expulsion ended a Medicaid practice that brought Barnes $117,000 in Medicaid billings in 1981 alone - amassed, the state said, while he was working 20 hours a week at the clinic, where he said he rented space from Spector.
Barnes refused to comment on the case. He is still in practice at 1001 S. 60th St. in Philadelphia.
In his student days at the Ohio College of Podiatric Medicine in Cleveland, Jay Robert Freifelder won prize after prize. He was elected student council president. He edited the school newspaper, Footprints.
Above all, he won the Galford Ethics Award in Forensic Medicine for his work at the college's Podiatric Clinic. The judges cited his devotion to patients, the quality of his record-keeping, his adherence to the rules and regulations of podiatry.
After graduation in the early 1970s he opened a clinic in the Johnson Homes section of Philadelphia. Then another in the Northeast. Business was good.
By 1980, Freifelder was billing Medicaid $68,973 for the year. Medicaid said he was the fourth-highest prescriber of orthopedic shoes in the state.
Then he gave foot examinations to Ferrara and Debra Troutman, another Bureau of Utilization Review official working undercover.
The two had been examined by a state podiatrist, who found no problems.
Ferrara said he simply asked Freifelder to check his feet.
"He look(ed) at my feet," Ferrara wrote in 1981, "and stated I had fluid on my right foot and ask(ed) about my arches, if they hurt. I responded noncommital to the question. I asked if I needed shoes for the arches. He stated he could write for them."
Ferrara said Freifelder gave him a prescription for corrective shoes. Diagnosis: Flat feet.
As for Troutman, Ferrara said Freifelder scraped callouses on both feet and scribbled down a prescription for corrective shoes.
And later Freifelder billed the state for a surgical procedure - an incision and drainage of an abcess.
"He billed for a surgical procedure but none was performed," Ferrara said. "And the shoes were not medically necessary."
It was just the start. Bureau of Utilization Review officials, digging deeper, said Freifelder had failed to keep adequate records for 47 patients. On other records he claimed he had performed nail excisions on four Medicaid patients. Officials said he never gave the treatments.
The state attorney general's office investigated next. It found 23 instances in which Freifelder billed the state for nail excisions, abscess drainage, X-rays and other services - yet patients told investigators they had never received them. For five other patients, he allegedly billed the state for more expensive services than he actually rendered.
On June 2, 1982, the podiatrist pleaded no contest to one Medicaid fraud charge and agreed to pay $615 in restitution for 22 others, plus $4,000 in fines. The Department of Public Welfare barred him from Medicaid until 1988.
Freifelder continues to practice. It was not until July 1985 that the State Board of Podiatric Examiners held a hearing on possibly revoking his license. Not until January did the board issue its decision: three months' suspension of license, stayed in favor of three months' probation.
In an interview, Freifelder said he would not comment on his case, because the events have been too painful. "I'm just trying to get my life together," he said.