Friday, August 13, 2010

Former Chicago Cardiologist Sentenced To 5 Years In Prison In Upcoding Case

On August 10, 2010, Sushil Sheth, age 50, a cardiologist who had privileges at three Chicago area hospitals, was sentenced by U.S. District Judge Rebecca Pallmeyer in a federal health care fraud case to a 60-month (5 year) federal prison term. His case was essentially an upcoding case where he allegedly billed at the highest level of care (99291 and 99292) where that level of care was not performed.

Dr. Sheth surrendered his medical license voluntarily and it was suspended by the Illinois Department of Professional Regulation in March 2010. As part of his sentence, he was ordered to pay approximately $13 million in restitution and forfeited property and funds totaling more than $11.3 million that the government seized from him.

This criminal case began with then Dr. Sheth being charged in January 2009 for billings to Medicare and other private health care companies between 2002 and 2007. He plead guilty a year ago pursuant to a Plea Agreement and Information (a copy of the Information is linked for those that would like to review the details).

As part of his plea, Dr. Sheth admitted that he obtained approximately $13 million, including approximately $8.3 million from Medicare and some $5 million from other public and private health care insurers—in fraudulent reimbursement for the highest level of cardiac care when those services were not performed—and then used the proceeds for his own benefit.

Dr. Sheth allegedly used his hospital privileges to access and obtain information about patients without their knowledge or consent. He was accused of hiring individuals to bill Medicare and other insurance providers for medical services that he purportedly rendered to patients whom he knew he never treated. Typically waiting almost a year after the treatment was purportedly provided, Dr. Sheth allegedly submitted more than 14,800 false claims for reimbursement for providing the highest level of cardiac care—requiring hands-on treatment in an intensive care unit—on multiple days during patients’ hospital stays.

One of the ways that the government intended to prove their case was to show that Dr. Sheth regularly submitted claims seeking payment that, when added together, had him providing more than 24 hours of medical services and treatment in a single day.

Since Dr. Sheth is Indian-American this case was of particular interest to this ethnic community. In my opinion, there needs to be outreach in the communities for immigrant physicians -- especially those who come from third world or less developed countries -- who are seemingly unaware of the harsh penalties for billing improprieties such as upcoding. The professional ethics that are taken for granted are cultural to a certain extent and education is essential for some physicians who move to the United States.  Even though the percentage of physicians who are foreign born that commit fraud is a minority, the perception is that foreign born physicians are more likely to engage in billing abuse, not familiarize themselves with the regulations and not realize that these are not always issues that can be resolved with the repayment of money.

The government is prosecuting upcoding cases more frequently. Previously, upcoding was left as an administrative remedy for agencies whereby they conducted an audit for overpayment. Now that government and private insurers computers are more sophisticated and the government and private sectors are working together, there is an effort to determine how many patients are seen per day in order to determine whether a case rises to the level of fraud.

Posted by Tracy Green, Esq.  Any questions regarding your own situation should be directed to Tracy Green, a very experienced health care fraud attorneyupcoding attorney and Medicare fraud attorney. You can email her at or call her at 213-233-2261.  

The firm focuses its practice on the representation of licensed professionals, individuals and businesses in civil, business, administrative and criminal proceedings. They have a specialty in representing health care providers  in health care fraud and other types of fraud and overbilling allegations in California and throughout the country. Their website is:


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