Thursday, December 31, 2015

Ohio Cardiologist Convicted at Trial and Sentenced to 20 Years in Federal Prison for Overbilling Medicare and Private Insurance & Allegedly Performing Unnecessary Procedures

Prosecutors are more aggressive in pursing physicians for criminal charges where just a few years ago the charges would be civil cases or administrative requests for overpayment. A high profile case out of Ohio went to trial for about three years, ended up with a jury convicting an Ohio cardiologist on 15 counts, and now a long sentence has been handed out.

Dr. Harold Persaud, 56, a cardiologist, was sentenced to 20 years in prison on December 18, 2015, for allegedly performing unnecessary catheterizations, tests, stent insertions and causing unnecessary coronary artery bypass surgeries from 2006 to 2012. The government's case was that this was part of his fraudulent billing to Medicare and other insurers.

One of the issues that arises in almost every criminal case against physicians is the issue of whether records have been falsified or whether there has been some false billing. This case was no different. Even a small percentage of false billing or fabricated records can serve to taint the case when viewed by the jury. Thirteen of the counts against the doctor were for making false statements. He was acquitted of one count of making a false statement. There was a monetary structuring charge as well of which he was convicted and this was probably brought in so that the government could argue the motive was financial or "greed."

When physicians in large practices review the allegations, one can see why compliance plans that include review of charts and billing can help prevent criminal cases. This can be more problematic with the electronic medical recordkeeping (EMR) templates that can make the charts look very similar due to the use of templates.

The government prosecutors claimed that Dr. Persaud, who was no longer practicing by the time of trial, allegedly did the following:

1. Dr. Persaud allegedly selected the billing code for each patient submitted to Medicare and private insurers and used codes that reflected a service that was more costly than that which was actually performed (known as "upcoding");

2. Dr. Persaud allegedly performed nuclear stress tests on patients that were not medically necessary;

3. Dr. Persaud allegedly knowingly recorded false results of patients’ nuclear stress tests to justify cardiac catheterization procedures that were not medically necessary;

4. Dr. Persaud allegedly performed cardiac catheterizations on patients at the hospitals and falsely recorded the existence and extent of lesions (blockage) observed during the procedures;

5. Dr. Persaud allegedly recorded false symptoms in patient records to justify testing and procedures on patients;

6. Dr. Persaud allegedly inserted cardiac stents in patients who did not have 70 percent or more blockage in the vessel that he stented and who did not have symptoms of blockage;

7. Dr. Persaud allegedly placed a stent in a stenosed artery that already had a functioning bypass, thus providing no medical benefit and increasing the risk of harm to the patient;

8. Dr. Persaud allegedly improperly referred patients for coronary artery bypass surgery when there was no medical necessity for such surgery, which purportedly benefitted Dr. Persaud by increasing the amount of follow-up testing he could perform and bill to Medicare and private insurers; and

9. Dr. Persaud allegedly performed medically unnecessary stent procedures, aortograms, renal angiograms and other procedures and tests.

The government contended that as a result of this, Dr. Persaud overbilled and caused the overbilling of Medicare and private insurers in the amount of approximately $29 million, of which Medicare and the private insurers paid approximately $5.7 million, according to court records. A hearing is scheduled for Jan. 27, 2016, to determine restitution.

A case such as this one becomes highly dependent on experts and the records can make or break the case. With poor recordkeeping or records that were amended or created at a date after the service, it creates all types of issues in securing expert witnesses for the defense. Good recordkeeping is critical and is one reason why regular self-audits and compliance plans are important as a safe harbor against fraud.

Posted by Tracy Green, Esq.
Office: 213-233-2261


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