Fox Chapel Cardiologist Convicted at Trial of Health Care Fraud Involving more than $13 Million of Insurance Billings
PITTSBURGH – After deliberating for two hours, a federal jury found Samirkumar J. Shah guilty of two counts of health care fraud, United States Attorney Scott W. Brady announced today.
Shah, 56, of Fox Chapel, Pa., was tried before United States District Judge David S. Cercone in Pittsburgh, Pennsylvania.
U.S. Attorney Brady stated, "Health care fraud threatens the safety and integrity of our entire health care system. Doctors and medical professionals like Dr. Shah who issue false diagnoses, order unnecessary testing and fraudulently bill Medicare and Medicaid in effect steal from the most vulnerable in our community. Today’s jury verdict sends a clear message to those who would do the same: if you commit health care fraud, you will be prosecuted to the fullest extent of the law."
"Health care fraud is a serious problem that impacts every American," said FBI Pittsburgh Special Agent in Charge Robert Jones. "It takes critical resources from our health care system and increases health care costs for everyone. Dr. Shah's disregard for safe patient care goes against the medical ethics he was to uphold. The FBI, with its law enforcement partners, will continue to allocate a significant amount of expert resources to investigate these crimes and hold those defrauding the system accountable."
The evidence introduced during the eight-day trial established that between 2008 and 2013, Shah, a practicing cardiologist, submitted fraudulent claims to private insurance companies—Highmark Blue Cross Blue Shield (Highmark), UPMC Health Plan (UPMC), and Gateway Health Plan (Gateway)—as well as government insurance programs—Medicare and Medicaid—for an outpatient treatment known as External Counter Pulsation, or ECP. ECP involves the use of a specialized bed equipped with pressure cuffs, which exert pressure upon patients’ lower extremities as a means to increase blood flow to the heart. The evidence at trial further demonstrated that insurers only reimbursed for ECP treatments of patients who suffered from disabling angina—or chest pain caused by decreased blood flow to the heart—and only when a physician supervised the treatment.
In total, Shah purchased 25 beds and offered ECP to patients at more than 18 locations in Western Pennsylvania, Ohio, New York, and Florida. The evidence also showed that, in order to acquire new patients, Shah advertised ECP as "the Fountain of Youth," claimed that it made patients "younger and smarter," and offered the treatment for a range of ailments other than disabling angina, including obesity, migraines, high blood pressure, low blood pressure, diabetes, and erectile dysfunction. After signing up new patients, including many patients who never experienced chest pain, Shah instructed his employees to indicate that every patient had disabling angina on billing sheets that were used to support false insurance claims. In certain instances, Shah never met patients for whom he billed for ECP treatments.
The evidence also showed that patients were required to undergo certain diagnostic ultrasounds as a precautionary measure prior to starting ECP—in part to rule out blood clots that could cause a stroke or heart attack during the treatment. Nevertheless, witness testimony established that Shah did not review any of the ultrasound imagery before approving new patients to begin ECP.
Likewise, contrary to health insurance requirements, ECP treatments routinely occurred while neither Shah nor any other medical doctor was present at his various locations. On one such occasion, a patient experienced an adverse event during his ECP treatment and had to be transported via ambulance to the hospital.
In addition to billing for ECP treatments that were not medically necessary and were not provided under direct physician supervision, Shah also double-billed insurers by using a so-called "bundled" ECP code, which accounted for and included payment for various incidental procedures, and then separately submitted claims for the same included procedures. The evidence at trial further established that during reviews initiated by various insurers, Shah routinely submitted fabricated patient files and made false statements concerning his practice, his patient population, his record keeping, and his compliance with applicable coverage guidelines.
During the period of Shah’s scheme, the evidence showed that he submitted ECP-related claims for Medicare, Medicaid, UPMC, Highmark, and Gateway beneficiaries, totaling more than $13 million and that he received reimbursement payments in excess of $3.5 million.
Judge Cercone set sentencing for November 6, 2019, at 11 a.m. The law provides for a maximum sentence of 10 years in prison, a fine of $250,000, or both. Under the Federal Sentencing Guidelines, the actual sentence imposed is based upon the seriousness of the offense and the prior criminal history, if any, of the defendant.
Assistant United States Attorneys Eric G. Olshan and Nicole Vasquez Schmitt prosecuted this case on behalf of the government, with the assistance of Assistant United States Attorney Philip O’Connor.
The Federal Bureau of Investigation and Pennsylvania Office of Attorney General, Medicaid Fraud Control Unit, conducted the investigation that led to the conviction of Shah.