Whistle-blower: How doctor uncovered nightmare

Oncologist's discovery leads to the downfall of a cancer treatment empire

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From the blue yarns tucked in a woven basket to the earth-tone carpeting and the solidity of the stone fireplace, every detail of the Crittenton Hospital Cancer Center's waiting room helps anxious patients feel embraced by warmth and comfort. Even the vaulted ceiling, crafted of gleaming cherry wood, suggests a religious sanctuary, not a medical clinic.

Two years ago, before St. John Health System acquired it, this was the foyer to Dr. Farid Fata's clinic, a tasteful yet grand reception area linking his private clinic to the hospital. It was an arrangement that lent Fata seemingly special status and enhanced his reputation with patients.

Yet at 10 a.m. on July 1, 2013, Monica Flagg felt dread as she entered this space, a full year after a routine urine test showed an M protein spike that led her physician to refer her to Fata, a well-known oncologist and hematologist. She was 51, the executive director of a state-licensed nonprofit — a competent woman facing the stress of a life-threatening illness.

She would wait close to two hours before being called for this, her first chemotherapy session.

A nurse opened the door for her. "Monica."

Inside the clinic, the designer surroundings faded as human chaos seeped in. The infusion nurses argued among themselves, uncertain about whether to deliver the treatment by injection or a slow drip. In the end, Flagg was given a single shot. By the time she returned home, she was exhausted and upset.

Later that day, she and her husband Stephen retreated to the deck outside their Rochester home, trying to relax. When a few raindrops splattered, she went upstairs to close the bedroom window. Turning back around, Flagg stumbled and fell on an open suitcase she had been unpacking.

Almost two years later, she still recalls the crunch of bone and her own anguish as she began to cry.

Internal alarm goes off

That sweltering Fourth of July week, Dr. Soe Maunglay, then 41, a Burmese-born oncologist newly settled in southeastern Michigan, was making hospital rounds for Fata, his employer. Soft-spoken and meticulous, Maunglay was wearing a suit jacket rather than a white lab coat, a habit he'd adopted from a Mayo Clinic-trained mentor.

An accident of timing, personal history, and incredible luck — good and bad — was about to unfold in Flagg's hospital room. The result would save lives and unleash a federal investigation into a long-esteemed physician, collapsing his elaborate medical empire, even as details about who uncovered the doctor's web of deceit, fraud and suffering remained unexplained.

Next month, before Fata is sentenced in a Detroit federal courtroom, Fata victims will describe the toll of being prescribed toxic medication and testing they didn't need. They will explain how their misplaced trust in a doctor they once revered tore apart their families, cost them the power to make choices about living or dying, and created lingering mental anguish and illness.

But it was Flagg's stumble over a suitcase, and Soe Maunglay's determined follow-through over the next weeks, that precipitated Fata's own fall.

Making Fata's rounds that July day, Maunglay checked for the first time on Flagg, hospitalized with two fractures in her left leg. Because Maunglay is a cancer doctor, he paid heed to her multiple myeloma diagnosis, the Velcade injection, and the medical record before him. It all triggered an internal alarm. .

"Who told you that you have cancer?" he asked her.

Clinics in seven cities

Fata's Michigan Hematology and Oncology Inc. (MHO) was the state's largest private cancer practice in 2013, with clinics in seven cities, its own pharmacy and diagnostic center, and 1,700 patients, virtually all of them assigned to Fata, the tireless physician. Those who needed proof of Fata's dedication could look to the doctor's work ethic — he often labored past midnight — or to the Swan for Life Foundation, a charity Fata established to help cancer patients and their families.

Today, MHO is gone and Fata is behind bars, awaiting sentencing for at least $34 million in fraudulent Medicare billings and a kickback scheme with a hospice. The criminal counts only hint at the human suffering behind the financial damages and raise questions about how Fata's schemes could go undetected so long, despite his many contacts, doctors, and huge roster of patients. As Brian McKeen, the malpractice lawyer now representing Flagg, says with outrage: "The one place a person should be safe is a hospital or doctor's office.

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Maunglay alone among Fata's former associates is willing or ready to speak publicly, while at least two dozen lawsuits target professionals associated with the practice.

Fata had a reputation for hiring doctors who superficially seemed like Maunglay — younger, with fledgling practices, often foreign-born, with few Michigan connections. "It was like 'The Firm,' " says Dr. Gary Salem, vice president for medical affairs at McLaren-Lapeer Regional Hospital, where Maunglay now works — recalling the sinister law firm in the John Grisham novel that sought out young, vulnerable lawyers.

After a lifetime of geographic dislocation and family tragedy, Maunglay might have seemed ideally cast for the role of a high-performing associate unlikely to cause trouble.

Yet in truth, his life had schooled him in professional integrity and high-stakes drama: His parents, a physician and nurse, had given Maunglay and his three brothers a blissful childhood in Rangoon, Burma, now known as Yangon, Myanmar. For a time, his father had been a United Nations volunteer in Sri Lanka, a role he took pride in, and both parents were outspoken opponents of the military government in control. Their boys were expected to become doctors: A family photo shows a smiling four-year-old Soe with a stethoscope around his neck.

That comfortable, principled and striving world collapsed in 1989, when Maunglay's father, a vibrant 52-year-old man, got sick. After a diagnosis of brain cancer, the illness progressed swiftly, taking his life three months later. Maunglay's life became an epic journey, marked by repeated tragedies and obstacles to his success and survival.

A younger brother collapsed on the college soccer field and died in 1993. The regime closed the medical school in Rangoon, over and over again.

Determined to support her surviving sons through medical school, Maunglay's mother won political asylum in the U.S., moving to northern California alone, studying for her R.N. certification, while working as a nanny and in home health care jobs at night.

Her schedule was relentless and surely exhausting. In 1994, she swerved off the road at 7 a.m. into a concrete fence, and died in the crash. "We were a family of six," Maunglay says, eyes clouding with sudden tears. "Then we were three."

Maunglay was tempted to quit but instead drew strength from his mother's example: He worked into the midnight sun at an Alaskan salmon cannery every summer, amassing 100-hour weeks to pay his medical school tuition and expenses in Istanbul.

Eventually, he made his way back to the United States, where he completed his internship, residency and an oncology fellowship, and married his wife Mary. After she began a residency in radiology in Michigan, he took a position with Fata, proud to be associated with Michigan's most successful oncology practice, one headed by a physician who had trained at the elite Memorial Sloan-Kettering Cancer Center in New York. When he walked into Monica Flagg's hospital room on July 4, he had worked in the practice for 11 months.

Maunglay has had enough

Doctors rotated through Fata's practice, perhaps staying long enough to find evidence of disorganization and dysfunction, rather than proof of ill intent. But by July 4, 2013, when Maunglay first looked in on Fata's patient, he was well-situated to uncover deeper wrongs: He had caught Fata in an outright lie a few months before, when Fata had insisted the clinics were enrolled in a professional quality program.

Maunglay's growing distrust and disenchantment with his employer had led him a few weeks earlier to give notice of his resignation, effective Aug. 9 — enough time to help patients move to new doctors, to transfer records, without disturbing their lives or disrupting the practice.

During that window of waiting, he encountered Flagg. That July 4 evening, after seeing Fata's patient at Crittenton in Rochester Hills, he shared the case fundamentals with his wife.

Even if she hadn't been eight months pregnant and tired, she would have been baffled by her husband's description of the patient's condition and treatment. He ticked off the notes from the patient's chart — all normal readings — and then the cancer diagnosis, the chemotherapy drug used to treat multiple myeloma.

"Are you trying to trick me?" his wife asked, confused.

Flagg talked that night to her husband, Steve Flagg, too, explaining that the doctor who'd visited her asked a lot of questions about her diagnosis. "It was as if he didn't think I had cancer," she confided, with hope in her voice.

'You don't have cancer'

Maunglay was stunned by what the hospital chart suggested. A cancer-free patient being given chemotherapy wasn't negligence; it was an atrocity. "It's oh my God, if he can do this to a person who has nothing. ..." he said one recent Saturday afternoon. "For me, one case like this was enough. How could a doctor do this? My father died of cancer. For most of us" — he waved his arms — "cancer is personal."

As a cancer specialist, he had a special understanding of the horror he was witnessing, its cruelty. Fata's choice of myeloma, a cancer of the plasma cells in bone marrow, bespoke a certain shrewdness, because of the subjectivity of diagnosis. It was a clever niche for false doctoring. "You cannot fake lung cancer," he says. "You cannot fake a tumor ..." But with this disease, a malevolent doctor could plausibly use the treatment itself as a smokescreen to obscure future questions.

Myeloma's early "smoldering" stage is signaled by relatively minor changes in blood chemistry. Maunglay and Dr. Craig Cole, an assistant professor of medicine at the University of Michigan and myeloma specialist, say someone with an elevated M protein level is properly monitored through blood and urine testing. Flagg's was high enough to qualify as MGUS — an entry-level condition that can be precancerous, but often is not.

Flagg was instead diagnosed for the more serious smoldering myeloma and singled out for Fata's brand of aggressive, unorthodox — and very expensive — treatment: she was subjected to three bone marrow biopsies and prescribed monthly intravenous immunoglobin injections (IVIG) that cost $4,000 each. Flagg despaired before every test, even fighting the diagnosis. "People would ask me how I was feeling. I felt fine. I had no symptoms!" she said.

When she complained to Fata about the invasive testing, he shrugged. She was angry about her diagnosis, he said, prescribing 25 doses of Xanax, an anti-anxiety drug. Ten months after their first appointment, Fata recalibrated the diagnosis to multiple myeloma — an incurable, often deadly cancer of the plasma in bone marrow — while preparing her for lifelong treatment. She was busy at work, reluctant to push back too strongly. Perhaps she was just upset. "My sister had breast cancer. My brother died of lung cancer. I've seen what it does to people," she says.

Flagg was younger and healthier than most multiple myeloma patients, Maunglay knew. Her bone marrow plasma cells — cells that become malignant in actual multiple myeloma cases — were being treated to receive insurance reimbursement. The money stream could flow for as long as Flagg survived.

That's what Maunglay saw, what he felt — something worse than he had ever imagined. Maunglay knew he had to act but he also had to be certain he was right.

On July 5, 2013, Maunglay took a deep dive into the patient's records. In the privacy of the MHO Clarkston office, he pored through the file, recorded on computer and in handwritten notes, seeking some justification for Fata's course of treatment. But every test result in the medical history confirmed his original reaction in the hospital: Flagg was being deliberately treated with high-risk drugs for a disease she did not have.

If the patient actually had this pernicious disease, Maunglay knew, the myeloma cells couldn't possibly be vanquished by a single dose of chemotherapy. But they were nonexistent in Flagg. Her abnormalities were so slight, Maunglay thinks, that she likely wouldn't need treatment before she was 100 years old. Three percent of people 50 and over have this condition — and 5 to 7 percent over 70 — but only 1 percent of those cases will progress to cancer in a year. "This is a patient he has been following for a long period of time," he says. "This is not an error. It is intentional."

His visit to Flagg in the hospital represented a small miracle of timing: In two or three months, a visiting oncologist would have expected to find her blood counts normal, her cancer in remission.

Maunglay returned to Flagg's hospital room at Crittenton over the weekend, insisting she get a second opinion.

He was forceful and clear, determined that she would listen. But his own crisis, he realized, was just beginning.

Fata caught in a lie

In his first months at MHO, Maunglay had tried to understand and accommodate his strange employer, Fata. From the beginning, MHO wasn't like other practices where Maunglay had worked. First, there'd been an awkward job offer dance, with Fata extending the offer in February 2012, and then delaying the start date after Maunglay had already left his previous position in Pensacola, Fla.

Once he'd arrived, Maunglay saw Fata was very busy, with a huge caseload of patients, attributing confusion to simple disorganization. He could help improve the practice, he decided. He designed new patient consent forms that conformed to a professional standard.

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Dr. Soe Maunglay's discovery of unnecessary cancer treatments led to conviction of Dr. Farid Fata.

An email from his first week at work documents his request for a staff meeting and a change in practice. He'd insisted that a physician be present in every office where chemotherapy was being given. "That was just good practice, the way I had learned it," he says. Fata acquiesced, but also moved Maunglay to the Lapeer and Clarkston offices, where neither their hours nor their patients overlapped. Fata was so protective of his patients — secretive, in fact — that he carried a pager with no backup, answering all calls himself. Maunglay asked him to carry a cellphone, like other doctors, "but he would always say, 'Let's work on it.' "

Maunglay next offered to help MHO win credentials from QOPI, a consortium that certifies oncology practices with high professional standards. Fata stalled, perhaps because approval is contingent on providing detailed case records. But after Maunglay persisted in a series of emails, Fata emailed the staff: "MHO has been QOPI certified for 3 consecutive years with high scores ... Let's hold off."

It was, Maunglay knew, a flat-out lie. "I see that he has no ethics, no professionalism. I started looking very quickly for other options," Maunglay recalls. A stream of young doctors interviewed for the position — "always young fresh-faced graduates, never anyone with experience."

When Maunglay decided to resign, Fata tried to dissuade him. He promised Maunglay's wife a job when she completed her residency and then, when that proved unsuccessful, brandished a non-compete clause in Maunglay's contract: If Maunglay's next job wasn't at least two hours away, Fata would sue.

"I cannot work with this guy," he decided. He was so intent on leaving that he and his wife put a down payment on a house in Monroe; he accepted a position with the Case Western Reserve University Cancer Center in Sandusky, Ohio. That way, he and his wife would each commute roughly an hour each way.

Now, stunned by Flagg's case and almost out the door at the time of this horrifying discovery, Soe Maunglay recognized Fata's advantage: The senior doctor's network of associations, his Memorial Sloan-Kettering training, and lengthy patient roster had impressed him initially, too. Some staff members, nurses and nurse practitioners, had worked there for years. Why would people believe him?

Maunglay couldn't sleep. Although he had intervened in Flagg's case, he suspected her treatment might "be the tip of the iceberg." How would he find out? It was hardly paranoid to imagine a scenario where Fata covers his own crimes, then concocts stories about the oncologist who quit. Who knew what a doctor capable of diagnosing fake cancer might do?

Looking for evidence

Flagg's case wasn't enough to shut down Fata. He was certain of that. So over the 4th of July weekend, Maunglay realized he needed to find "very solid, very objective" evidence of wrongdoing, an anomaly that even a layperson might understand readily. But he worried, too: "What if this takes six months? What if I can't find it?

Hindsight may be laser-sharp, but Fata had withstood auditing from insurance companies, at least one malpractice lawsuit, state regulators and the scrutiny of other doctors in and outside his practice for a decade. He had dispensed cruelty as casually as Tylenol, without anyone catching him. Maunglay had witnessed some of his techniques: He had been kept from Fata's patients entirely, except for cursory interactions. "If a patient has a cough that worries him, he would have the patient drive 30 minutes to his office instead of coming to me in five minutes," says Maunglay.

Over the next several days, Maunglay's search of the records enabled him to find obvious breaches of professional ethics and likely fraud: He noticed a protocol for treating non-Hodgkins lymphoma with rituximab, a targeted cancer drug. He researched the use of intravenous immunoglobulins (IVIG), discovering that, as he suspected, they were being prescribed excessively, and without any apparent medical basis, on a large number of patients.

Knowing that he needed allies, he described his concerns to an infusion nurse and a nurse practitioner, sharing details about the excessive use of IVIG, and persuading them to intervene (The nurses would not comment for this story.) At least one of them confronted Fata directly, before resigning. "At that point, Fata is kind of caught," says Maunglay, saying Fata agreed to stop using IVIG except in cases where there were clearly accepted medical reasons for doing so. To Maunglay, that in itself was further proof of Fata's deceit.

"If a physician truly believed his own protocol is helping his patients, he would never discontinue a treatment just because another physician and staff objects. We caught him in the act," says Maunglay.

Even then, though, there was no clear way forward: Maunglay had reported some of his concerns to George Karadsheh, the practice manager, who was not a doctor. After the IVIG treatments stopped, he and Karadsheh met again in the Clarkston office. Together, they looked at a month of patient records, everyone who had IVIG, pulling up the records on Maunglay's computer monitor. "It was, 'Look at this. Some patients are correct then, look, this one does not meet the criteria. Look, this is Medicare fraud.' "

"He was convinced and revealed to me that he had experience reporting Medicare insurance fraud ... and he understands the seriousness of the fraud and abuse," Maunglay wrote, in a recent email. Karadsheh had, in 1996, uncovered fraud at Detroit's Lafayette Clinic and reported it under the False Claims Act, the federal whistle-blower law.

Karadsheh did not respond to repeated telephone calls and emails from The Detroit News. What he did do, according to Maunglay and information in federal documents, was assume the role of whistle-blower, as he and Maunglay agreed. It was Karadsheh who first spoke to the Federal Bureau of Investigation on Friday, August 2, 2013.

At 8 p.m. Aug. 5, Maunglay arrived home from work to find his wife introducing him to visitors: two federal agents, one from the FBI, another from the federal department of Health and Human Services.

"I've been waiting for you guys," he said, with a slight smile.

That evening, he laid out, as specifically as he could, results of his research over the previous few weeks. The excessive drug treatments, unusually aggressive treatment for terminally ill and old patients, protocols that didn't meet any accepted criteria. The agents took notes. Maunglay thought: Finally. Something is finally going to happen.

He didn't expect what happened next.

Fata arrested next day

At 7 a.m. on Aug. 6 — not even 12 hours later — agents arrested Fata in his Chevy SUV. By the time Crittenton Cancer Center staff arrived at work, federal agents already were swarming the office. "They did not let another drop of chemo go into anyone. They just pulled the plug," Maunglay says.

Despite Maunglay's belief that Fata likely treated other healthy patients for cancer, only two are known: Flagg and another patient, who sought a second opinion after Fata's arrest in 2013. The Flaggs are suing Fata (but not Maunglay) for malpractice.

"Hers is one of the glaring examples of people being abused by his out and out greed. He let greed cloud his clinical judgment," says Flagg's lawyer, Brian McKeen. "I have been doing this for 30 years and this is some of the most evil conduct I have ever seen."

On Sept. 16, 2014, Fata pleaded guilty to multiple counts of Medicare and insurance fraud, money laundering, and soliciting kickbacks, while publicly admitting that he'd prescribed treatments that were medically unnecessary. His assets were auctioned, and his wife and three children were allowed to leave the country. Fata is being held at the federal detention center in Milan, awaiting his court appearance July 6. Federal prosecutors are seeking a life sentence. Fata's lawyer has steadfastly declined comment but is expected to file a response under seal next week.

But the burden of association with Fata weighs heavily on Maunglay. Although his reputation as a doctor enabled him to secure a position at McLaren-Lapeer/Karmanos Cancer Center, he worries that, no matter how ethical or excellent a doctor he may be, he is forever linked to Fata and one of the nation's most horrific medical schemes. Once again, the future is uncertain and almost certainly difficult. "The person who speaks out is never OK," he says with a sigh.

Geraldine Parkin, who heads Patients and Families Treated by Dr. Fata, an advocacy group, voices the concerns of many who are appalled by how long Fata's crimes escaped detection. How could the other physicians not have known something?

"They say that he (Maunglay) is the whistle-blower, but I am still suspicious. His name is all over the charts," says Parkin, whose husband was a Fata patient.

Maunglay, though, had little access to Fata's patients. Because Maunglay had insisted that a physician always be present in the clinic during any chemotherapy, he signed charts, as all the doctors did. Fata's willingness to work 20 hours a day seemed exemplary, rather than a desperate strategy to avoid suspicion.

"It was just not that easy to know," Maunglay says.

Bart Buxton, the CEO at McLaren-Lapeer Regional Hospital, where Maunglay now works, had met Maunglay a year earlier, recognizing him as an unusually empathetic physician, and offered him a job closer to his wife's work, beginning that August. "He saved people's lives," he says. "It goes to the fiber and testament of the man. He's a hero."

Despite their life-changing encounter at Crittenton Hospital, Maunglay and Flagg have not spoken since. Flagg has tried to put the incident behind her and never reached out to Maunglay, the doctor who warned her about Fata. Yet their brief meetings had profound and lasting consequences — a potent combination of circumstance and personality coalescing at the right moment.

If it had not been for Flagg's broken leg, on the very first day of what was supposed to be a lifetime of chemotherapy, Fata might be practicing still. If Maunglay had been less observant, or perhaps less suspicious of Fata, he would have left the practice as he had planned, exiting quietly as so many had before.

No matter what lies ahead, Maunglay does not regret his decision to alert Monica Flagg and build a case against Fata. In a life that has been shattered by death, displacement and an ongoing medical horror story, he is resolute.

To explain, he sends a picture of Daniel, his 18 month-old son, standing in his socks with a Lego in his hand and a lopsided smile.

"You want to live the right way," he says.

lberman@detroitnews.com

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