Santa Fe Cardiologist Pleads Guilty to Federal Health Care Fraud Charge
Defendant Agrees to Two-Year Prison Sentence
ALBUQUERQUE – Roy G. Heilbron, 53, a cardiologist practicing in Santa Fe, N.M., pleaded guilty today in federal court in Albuquerque, N.M., to a health care fraud charge, announced U.S. Attorney Damon P. Martinez and Special Agent in Charge Terry Wade of the FBI’s Albuquerque Division. Under the terms of the plea agreement, Heilbron will be sentenced to two years in federal prison followed by a term of supervised release to be determined by the court.
Heilbron was charged with health care fraud and wire fraud charges in a 24-count indictment that was filed in June 2015. The indictment alleged that Heilbron, a physician licensed to practice medicine in New Mexico who specializes in cardiology, executed a scheme to defraud Medicare and other health care benefit programs between Jan. 2010 and May 2011 by submitting false and fraudulent claims. According to the indictment, Heilbron executed his fraudulent scheme by:
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;
Inserting false symptoms, observations, and diagnoses into patients’ medical charts to provide written support for the tests he ordered or performed;
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;
Submitting the photocopied notes, results, and images to the insurance plans when the plans requested documentation to support the claims submitted;
Submitting claims to health plans for procedures that were never performed;
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
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. 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 Jan. 20, 2010 and May 5, 2011. 22 through 24 charged Heilbron with committing wire fraud by using wire communications to obtain payments from health care benefit programs.
During a change of plea hearing today, Heilbron pled guilty to Count 4 of the Indictment, a health care fraud charge. In his plea agreement, Heilbron acknowledged that at all times relevant to the crimes charged in the indictment, he was a doctor involved in the private practice of medicine. Heilbron further admitted from Dec. 2009 through Dec. 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, 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, Heilbron admitted devising and executing a scheme to deceive and obtain money from health care programs that covered his patients by misrepresenting his patients’ diagnoses.
Although Heilbron pled guilty to only one count of the indictment, in his plea agreement, Heilbron 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.
This case was investigated by the Santa Fe and Albuquerque offices of the FBI and is being prosecuted by Assistant U.S. Attorneys Jeremy Pena, George C. Kraehe and C. Paige Messec.