Special to the NEWS
BROWNSVILLE, TX—Six South Texas doctors, including one from San Benito, and their practices have agreed to pay $4,855,844 to resolve allegations that they submitted false claims to Medicare, Medicaid, and TRICARE for services that were not rendered or were not medically necessary, announced U.S. Attorney Nicholas J. Ganjei.
According to a DOJ press release, Drs. Javier Cabello, 47, of San Benito; Ammar Halloum, 52, of Brownsville; Jamil Madi, 54, of Olmito; Jairo Rodriguez, 62, of Rancho Viejo; Ricardo Schwarcz, 57, of Weslaco; and Stanley Sy, 55, of Pharr, 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.
According to the DOJ, from Jan. 1, 2020, to May 31, 2023, BIS, BPC, and its owners allegedly submitted claims for critical care, and BPC and Rodriguez also allegedly submitted claims for pulmonary function testing.
Patients’ medical records allegedly did not support this care or 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, according to the press release.
According to the allegations, BIS providers instead billed for critical care for stable patients, unnecessary follow-up visits, or services they never performed.
PFT services include tests that assess 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 document the indications and presentations for the order of testing in the patient’s medical record.
BPC and Rodriguez allegedly billed for unnecessary routine PFT services or for services they never performed.
As a result, Medicare, Medicaid, and TRICARE allegedly either paid significantly more for critical care claims or for PFT claims that should never have been submitted to the government programs, states the DOJ.
“This outcome emphasizes the Southern District of Texas’s commitment to vigorously investigate and disrupt civil health care fraud, wherever it may be,” said 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.”
“We remain steadfast in our mission to protect patients and safeguard federal health care programs,” said Special Agent in Charge Jason E. Meadows of the Department of Health and Human Services – Office of Inspector General.
“This settlement underscores our commitment to holding providers accountable for submitting claims for services that are not medically necessary or were not actually provided. We will continue to work closely with our law enforcement partners to ensure that taxpayer-funded programs are protected from fraud and abuse,” he added.
“Fraud against the government will not be tolerated,” said Acting Special Agent in Charge Alex Doran of the FBI San Antonio Field Office. “Submitting false claims to federal health care programs during a national emergency, such as the COVID-19 pandemic, steals from taxpayers and exploits vulnerable patients. The FBI, together with its federal and state partners, will hold accountable anyone who seeks to profit by defrauding the United States.”
The settlement stems from a qui tam (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.
DHHS-OIG and the FBI conducted the investigation with assistance from the Defense Criminal Investigative Service and the Texas Attorney General’s Office – Civil Medicaid Fraud Division. Assistant U.S. Attorney Laura E. Collins handled the matter.
According to the statement, the claims resolved by the settlement are allegations only, and there has been no determination of liability.
2 comments
My husband went to one of these physicians and underwent tests they mentioned here. We had to pay multiple copays and he prescribed an inhaler that cost 300.00/month! When I tried explaining to him we couldn’t keep paying that much, he just told my husband that was the best one and dismissed me.
I knew five of these physicians…so ashamed