Friday, March 10, 2017

Cardiologist Pleads Guilty to Federal Health Care Fraud Charges From 2010 and 2011 for Submitting False Claims and Records

On February 17, 2017, Roy G. Heilbron, a cardiologist practicing in Santa Fe, New Mexico, pleaded guilty in federal court in Albuquerque to a health care fraud charge, Count 4 from his 2015 Indictment. 

Dr. Heilbron's 24-count indictment originally charged him with health care fraud and wire fraud charges for allegedly defrauding Medicare and other health care benefit programs between January 2010 and May 2011 by submitting false and fraudulent claims in the following manner:

1.  Performing and billing for a wide array of unnecessary tests on every new patient and submitting false diagnoses with the billing claims to justify the tests to the insurance plans;
2.  Inserting false symptoms, observations, and diagnoses into patients’ medical charts to provide written support for the tests he ordered or performed;
3.  Inserting photocopied clinical notes, diagnostic test results, and ultrasound images in patients’ medical charts to create a written record of procedures that were either not performed or that had not been sufficiently documented to support the billing;
4.  Submitting the photocopied notes, results, and images to the insurance plans when the plans requested documentation to support the claims submitted;
5.  Submitting claims to health plans for procedures that were never performed;
6.  Submitting claims for procedures performed on two consecutive dates to increase the amount paid for services that were actually rendered together on one single date; and
7.  Misusing billing codes and modifiers in order to increase his rate of reimbursement.

Counts 1 through 9 of the indictment charged Heilbron with committing health care fraud by submitting false claims for medical services rendered to health care benefit programs on nine dates between July 13, 2010 and Feb. 10, 2011. Charges 10-21 charged Heilbron with committing health care fraud by submitting falsified medical records for medical services to health care benefit programs on twelve occasions between January 20, 2010 and May 5, 2011. Charges 22 through 24 charged Heilbron with committing wire fraud by using wire communications to obtain payments from health care benefit programs. His plea was only to Count 4. This is common during plea negotiations.

During the change of plea hearing, Dr. Heilbron pled guilty to Count 4 of the Indictment, a health care fraud charge. In his plea agreement, Dr. Heilbron admitted from December 2009 through December 2011, he provided medical services as A Well for Health Church, Inc., a medical clinic in Santa Fe, where he contracted with several health care benefit programs including Blue Cross and Blue Shield of New Mexico and Medicare. Under the terms of those contracts, Dr. Heilbron would bill the programs for medical services he provided to patients covered by those programs and included his medical diagnosis or other justifications for the services for which he requested compensation. In his plea agreement, Dr. Heilbron admitted to billing health care programs that covered his patients by misrepresenting his patients’ diagnoses.

Although Dr. Heilbron pled guilty to only one count of the indictment, in his plea agreement, he agreed to pay restitution based on all of the criminal conduct charged in the indictment. The amount of restitution will be determined by the court after the presentation of evidence and argument by the parties.

Under the terms of the plea agreement, Dr. Heilbron will be sentenced to two years in federal prison followed by a term of supervised release to be determined by the court.

Posted by Tracy Green, Esq.
Office: 213-233-2260 


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