Medicare
fraud cases involving chiropractors are not very common. The reason for this is
that Medicare severely limits coverage for chiropractic services to manual
manipulation of the spine to correct a condition known as “subluxation.” The
diagnosis of subluxation must be diagnosed and documented either by X-ray or a
physical examination that is detailed and documented before Medicare will
reimburse. Medicare does not pay for maintenance therapy or for chiropractic
treatments that are for maintenance or to promote health.
In Los
Angeles, a chiropractor, Danny Paveh (also known as Houshang Pavehzadeh) of the
Sylmar Physician Medical Group, was charged in May 2013 with federal health
care fraud (18 USC 1347), aggravated identity theft (18 USC 1028(A)(1), and
forfeiture allegations. Dr. Paveh is presumed innocent and the fact that an
Indictment has been filed is not evidence. This case is pending in the U.S.
District Court for the Central District before Judge Manuel L. Real. Mr. Paveh was released on $100,000 bond and a trial date is not yet set.
The
allegations in this case are that from 2005 to 2012 – a very long billing
period – Chiropractor Paveh billed Medicare more than $1.7 million for
chiropractic treatments for subluxation that were never properly performed.
The government alleges that the patients only received massages and other
non-reimbursable treatments from Dr. Paveh and massage therapists who worked at
his group. Essentially, the government alleges that these were “false claims”
submitted to Medicare. It is also alleged that Dr. Paveh committed “aggravated
identity theft” by taking the patients information and billing Medicare.
Attorney
Commentary Regarding This Chiropractor Medicare Fraud Case
First, it
appears that Dr. Paveh may have come to the government’s attention via an audit
to be performed by OIG. According to the government, Dr. Paveh was the second-largest
Medicare biller in California for chiropractic services – even though he was
the only chiropractor in his group. The government also alleged that he was not
in the United States when some of the services were performed.
Second, although
clients can panic when faced with an audit, the government alleges that when
OIG investigators tried to conduct an audit of Pavehzadeh’s claims, he falsely
reported to the Los Angeles Police Department that he had been carjacked and
that patient files requested by the auditors had been stolen from his car. This
could be used as a sentencing enhancement and to show false statements to
government officials in conducting an audit.
Third, I
often see clients who assume because they have billed certain procedures for
years that it means that Medicare must not have an issue with the billing or
documentation. Unfortunately, Medicare is known as “good faith” billing and it
reserves the right to go back and audit and seek an overpayment in an
administrative context or to seek criminal charges as was done here. Thus,
years of billing does not guarantee that the government will not take action.
Health care has changed over the years and Medicare has become much more
aggressive in health care fraud cases.
Fourth, this
case was being investigated for some years. This means that there was
significant time to meet with the federal prosecutors and see if the case could
be settled pre-indictment. In some cases, we are able to have the prosecutors
offer a “reverse proffer” so the client and Medicare fraud attorney can see
what evidence the government has so the case can be realistically assessed.
Finally, forfeiture allegations were filed in this case which can often tie up a defendant's assets and make it more difficult to defend oneself or to support oneself pending a trial. In evaluating anyone's potential exposure, it should be assumed that forfeiture allegations will be filed in any federal health care fraud case.
In
cases like this, obtaining representation long before Indictment – and ideally
at the audit stage – make the most sense so the case does not grow and if there
are adverse facts, they can be handled at the earliest stage. If there is
exculpatory evidence and facts that show innocence and good faith billing, then
those facts can be presented as well.
Posted by
Tracy Green, Esq.