Six South Texas doctors and their practices will pay $4,855,844 to resolve charges that they filed false claims to Medicare, Medicaid and TRICARE for services not provided or not medically necessary.
In a settlement announced last week, U.S. Attorney Nicholas J. Ganjei reported Drs. Javier Cabello, Ammar Halloum, Jamil Madi, Jairo Rodriguez, Ricardo Schwarcz, and Stanley Sy, owned and operated Benchmark Inpatient Services PLLC dba Beyond Inpatient Services in Harlingen. Rodriguez also owned and operated Brownsville Pulmonary Center, P.A. dba Benchmark Pulmonary Center, Brownsville.
From Jan. 1, 2020, to May 31, 2023, the Justice Department alleged BIS, BPC, and its owners submitted claims for critical care, while BPC and Rodriguez also allegedly submitted claims for pulmonary function testing. Patients’ medical records allegedly did not support this care and testing, or the care was not rendered at all.
Critical care billing requires complex decision-making and at least 30 minutes of treatment for a critically ill or injured patient. BIS providers instead billed critical care for stable patients, unnecessary follow-up visits, or services they never performed, according to the allegations.
PFT services include various tests that demonstrate how well the lungs function. When medically necessary, PFT services either diagnose and evaluate new respiratory symptoms or assess a patient’s current therapeutic respiratory interventions.
Medicare does not reimburse for routine PFT services. For Medicare to reimburse for medically necessary PFT services, providers must describe the indications and presentments for the order for testing in the patient’s medical record.
The Justice Department charged BPC and Rodriguez instead allegedly billed PFT services for unnecessary routine testing or services they never performed.
As a result, Medicare, Medicaid, and TRICARE either paid significantly more for critical care claims or for PFT claims that should never have even been made to the government programs.
Department of Health and Human Services Office of Inspector General leaders say this settlement underscores HHS’ commitment to holding providers accountable when they submit claims for services that are not medically necessary or not actually provided.
“This outcome emphasizes the Southern District of Texas’s commitment to vigorously investigate and disrupt civil health care fraud, wherever it may be,” the announcement quotes Ganjei. “Our country’s most vulnerable deserve care based on their medical need, not on a doctor’s unscrupulous desire to line their own pockets. Medical professionals have a solemn obligation to heal the sick and infirm, not to bilk the American taxpayer.”
The settlement stems from a qui tam or whistleblower complaint filed under the False Claims Act which permits a private party to file an action on behalf of the United States and receive a portion of any recovery. Qui tam and other whistleblower claims are a common source of investigations, resulting in these types of settlements or other civil or criminal convictions.
DHHS-OIG and FBI conducted the investigation with assistance from Defense Criminal Investigative Service and Texas Attorney General’s Office – Civil Medicaid Fraud Division. Assistant U.S. Attorney Laura E. Collins handled the matter.
The investigation and resulting settlement alert healthcare providers to continue to be vigilant in their treatment and billing practices. Along with the federal government programs involved in this settlement, private sector healthcare programs also now conform the basis of false claims as a result of amendments enacted as part of the Health Insurance Portability and Accountability Act reforms. Healthcare providers should use care to ensure that they comprehensibly document all care and its justification and verify that all required elements to qualify for the reimbursement sought are complete completed and defensible before submitting a bill for public or private insurance coverage.
If you have questions about this or other health care concerns, contact the author.
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We hope this update is helpful. For more information about the or other health or other employee benefits, human resources, or health care developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297.
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About the Author
Peer recognized as “Top Rated Lawyer” and “LEGAL LEADER™ “Top Rated Lawyer” and “Best Lawyer” for her work in Health Care Law, Labor and Employment Law; ERISA & Employee Benefits,” and “Business and Commercial Law,” Cynthia Marcotte Stamer is an A Martindale-Hubble “AV-Preeminent” (Top 1%) attorneys board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for her more than 35 years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications including leading edge work on PBM, pharmacy and pharmaceutical and other health care, managed care, insurance, and insured and self-insured contracting, design, administration and regulation..
Author of numerous highly regarded works on health law and policy, Immediate Past Chair of the ABA International Section Life Sciences Committee and the current Tort Trial and Insurance Practice Section Medicine and Law Committee, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group and past Group Chair and current Welfare Benefit Committee Co-Chair of the ABA RPTE Employee Benefits & Other Compensation Group, Ms. Stamer is most widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health and other privacy and data security and other health industry legal, public policy and operational concerns.
Ms. Stamer’s work throughout her career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. As a part of this work, she has continuously and extensively worked with domestic and international health plans, their sponsors, fiduciaries, administrators, and insurers; managed care and insurance organizations; third party administrators and other health benefit service providers; hospitals, health care systems and other health care providers, accreditation, peer review and quality committees and organizations; billing, utilization management, management services organizations, group purchasing organizations; pharmaceutical, pharmacy, and prescription benefit management and organizations; consultants; investors; EMR, claims, payroll and other technology, billing and reimbursement and other services and product vendors; products and solutions consultants and developers; investors; managed care organizations, self-insured health and other employee benefit plans, their sponsors, fiduciaries, administrators and service providers, insurers and other payers, health industry advocacy and other service providers and groups and other health and managed care industry clients as well as federal and state legislative, regulatory, investigatory and enforcement bodies and agencies.
She also has extensive experience helping health care systems and organizations, group and individual health care providers, health plans and insurers, health IT, life sciences and other health industry clients prevent, investigate, manage and resolve sexual assault, abuse, harassment and other organizational, provider and employee misconduct and other performance and behavior; manage Section 1557, Section 504, Civil Rights Act and other discrimination and accommodation, and other regulatory, contractual and other compliance; vendors and suppliers; contracting and other terms of participation, medical billing, reimbursement, claims administration and coordination, Medicare, Medicaid, CHIP, Medicare/Medicaid Advantage, ERISA and other payers and other provider-payer relations, contracting, compliance and enforcement; Form 990 and other nonprofit and tax-exemption; fundraising, investors, joint venture, and other business partners; quality and other performance measurement, management, discipline and reporting; physician and other workforce recruiting, performance management, peer review and other investigations and discipline, wage and hour, payroll, gain-sharing and other pay-for performance and other compensation, training, outsourcing and other human resources and workforce matters; board, medical staff and other governance; strategic planning, process and quality improvement; meaningful use, EMR, HIPAA and other technology, data security and breach and other health IT and data; STARK, ant kickback, insurance, and other fraud prevention, investigation, defense and enforcement; audits, investigations, and enforcement actions; trade secrets and other intellectual property; crisis preparedness and response; internal, government and third-party licensure, credentialing, accreditation, HCQIA and other peer review and quality reporting, audits, investigations, enforcement and defense; patient relations and care; internal controls and regulatory compliance; payer-provider, provider-provider, vendor, patient, governmental and community relations; facilities, practice, products and other sales, mergers, acquisitions and other business and commercial transactions; government procurement and contracting; grants; tax-exemption and not-for-profit; privacy and data security; training; risk and change management; regulatory affairs and public policy; process, product and service improvement, development and innovation, and other legal and operational compliance and risk management, government and regulatory affairs and operations concerns. to establish, administer and defend workforce and staffing, quality, and other compliance, risk management and operational practices, policies and actions; comply with requirements; investigate and respond to Board of Medicine, Health, Nursing, Pharmacy, Chiropractic, and other licensing agencies, Department of Aging & Disability, FDA, Drug Enforcement Agency, OCR Privacy and Civil Rights, Department of Labor, IRS, HHS, DOD, FTC, SEC, CDC and other public health, Department of Justice and state attorneys’ general and other federal and state agencies; JCHO and other accreditation and quality organizations; private litigation and other federal and state health care industry actions: regulatory and public policy advocacy; training and discipline; enforcement; and other strategic and operational concerns.
A popular speaker and t of hundreds publications on False Claims and other health care compliance, risk management, and enforcement, and a multitude of other highly regarded publications and presentations, Ms.Stamer is widely recognized for her thought leadership on a multitude of other health care, health plan and other health industry matters. In addition, Ms. Stamer contributes her time and leadership to numerous policy, professional, civil and other organizations including service as the, the American Bar Association (ABA) International Section Life Sciences Committee Vice Chair, a Scribe for the ABA Joint Committee on Employee Benefits (JCEB) Annual OCR Agency Meeting and a former Council Representative, Past Chair of the ABA Managed Care & Insurance Interest Group, former Vice President and Executive Director of the North Texas Health Care Compliance Professionals Association, past Board President of Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency, past North Texas United Way Long Range Planning Committee Member, and past Board Member and Compliance Chair of the National Kidney Foundation of North Texas, and a Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also shares her extensive publications and thought leadership as well as leadership involvement in a broad range of other professional and civic organizations. For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.
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