February 8, 2023

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Fox Chapel Cardiologist Sentenced to 78 Months in Prison for Wellbeing Care Fraud Scheme Involving Additional Than $13 Million of Insurance coverage Billings | USAO-WDPA

PITTSBURGH – A resident of Fox Chapel, Pennsylvania, was sentenced in federal courtroom next his conviction at trial on two counts of health treatment fraud, Performing United States Lawyer Stephen R. Kaufman announced now.

United States District Decide David S. Cercone sentenced Samirkumar J. Shah, 58, to 78 months of imprisonment followed by a few yrs of supervised launch.

“Dr. Shah risked the wellness of his individuals so he could make thousands and thousands of pounds by way of avoidable processes, and lied and fabricated data for years to perpetuate his fraud plan,” reported Performing U.S. Attorney Kaufman. “This prosecution demonstrates our dedication to defend the health care process from fraud and sends a distinct information of deterrence to other individuals who could possibly take into account comparable criminal actions.”

“Today’s sentence retains Mr. Shah accountable for his appalling steps,” reported FBI Pittsburgh Specific Agent in Charge Mike Nordwall. “Mr. Shah utilized his placement as a medical professional to illegally earnings from a healthcare plan paid for by taxpayers. Fraud of this magnitude will not be tolerated. The FBI, along with our associates, are fully commited to creating guaranteed the integrity of our health care reward plans continues to be intact and will always operate diligently to examine and keep accountable those people who feel they can steal from the method.”

“Rather than upholding the oath he swore and delivering treatment for individuals who trusted him, this defendant misled patients and drained important Medicaid money from households who needed it,” reported Attorney Basic Josh Shapiro. “We will not allow any person set their patients’ lives at threat for a earnings.”

Shah was convicted on June 14, 2019, following an 8-day jury demo in Pittsburgh. The evidence launched at trial set up that between 2008 and 2013, Shah, a training cardiologist, submitted fraudulent statements to personal coverage plans—Highmark Blue Cross Blue Shield (Highmark), UPMC Well being System (UPMC)—as perfectly as government insurance programs—Medicare and Medicaid (as a result of Gateway Wellbeing Prepare)—for an outpatient cure regarded as external counterpulsation, or ECP. ECP will involve the use of a specialised bed geared up with strain cuffs, which exert pressure to patients’ lower extremities as a indicates to maximize blood stream to the coronary heart. The evidence at trial additional shown that insurers only reimbursed for ECP remedies of people who endured from disabling angina—or considerable chest discomfort prompted by diminished blood movement to the heart—and only when a medical doctor supervised the treatment.

In full, Shah obtained 25 beds and supplied ECP to clients at much more than 18 spots in Western Pennsylvania, Ohio, New York, and Florida. The proof also confirmed that, in buy to acquire new clients, Shah advertised ECP as “the Fountain of Youth,” claimed that it designed individuals “younger and smarter,” and supplied the remedy for a array of illnesses other than disabling angina, like being overweight, migraines, high blood strain, lower blood pressure, diabetes, and erectile dysfunction. Following signing up new clients, such as quite a few people who in no way expert upper body agony, Shah instructed his staff members to indicate that each and every individual experienced disabling angina on billing sheets that were utilized to guidance untrue insurance plan statements. In particular circumstances, Shah never satisfied sufferers for whom he billed for ECP remedies.

The proof also confirmed that clients were essential to endure sure diagnostic ultrasounds as a precautionary measure prior to setting up ECP—in portion to rule out blood clots that could induce a stroke or heart attack through the remedy. Yet, witness testimony proven that Shah did not evaluate any of the ultrasound imagery before approving new clients to start out ECP, putting his individuals at chance of really serious injuries or even dying.

Also, contrary to overall health insurance specifications, ECP treatment options routinely occurred although neither Shah nor any other clinical health care provider was present at his several areas. On one particular these types of event, a individual knowledgeable an adverse occasion all through his ECP treatment and had to be transported via ambulance to the hospital.

In addition to billing for ECP therapies that have been not medically important and were not provided beneath immediate health practitioner supervision, Shah also double-billed insurers by using a so-identified as “bundled” ECP code, which accounted for and bundled payment for many incidental techniques, and then individually submitting statements for the identical provided methods. The evidence at trial additional set up that during opinions initiated by different insurers, Shah routinely submitted fabricated client data files and produced fake statements relating to his practice, his individual populace, his file trying to keep, and his compliance with applicable protection pointers.

Through the period of Shah’s scheme, the evidence showed that he submitted ECP-related claims for Medicare Part B, UPMC, Highmark, and Gateway beneficiaries, totaling much more than $13 million and that he received reimbursement payments in surplus of $3.5 million.

As aspect of his sentence, Shah ought to pay out restitution totaling about $1.2 million to the target insurers, as effectively as a $500,000 forfeiture money judgment.

Shah unsuccessful to surface for his first sentencing day on July 14, 2021, and he has been custody considering that the following day following Choose Cercone issued a warrant for his arrest.

Assistant United States Attorneys Eric G. Olshan and Nicole Vasquez Schmitt prosecuted this case on behalf of the governing administration.

The Federal Bureau of Investigation and Pennsylvania Place of work of Attorney Normal, Medicaid Fraud Handle Unit, conducted the investigation that led to the conviction of Shah.