[a $250,000 fine for more than $13 million in insurance claims]
A federal jury in Pittsburgh deliberated just 2 hours before finding cardiologist Samirkumar J. Shah, MD, guilty on two counts of fraud related to more than $13 million in insurance claims for external counterpulsation (ECP) therapy, the US Department of Justice has announced.
ECP treatment uses inflatable cuffs wrapped around the lower extremities to increase venous return and augment diastolic blood pressure. Enhanced ECP gained US approval in 1995 for the treatment of patients with CAD and refractory angina.
Evidence during the 8-day trial showed that Shah, 56, of Fox Chapel, Pennsylvania, advertised ECP as the "Fountain of Youth," claimed it made patients "younger and smarter," and offered treatment for conditions other than disabling angina, including obesity, hypertension, hypotension, diabetes, and erectile dysfunction.
Insurers, however, only reimbursed for ECP for patients with disabling angina and only when a physician supervised treatment.
"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," says the June 14 news release.
Shah owned 25 beds and offered ECP to patients at more than 18 locations in Western Pennsylvania, Ohio, New York, and Florida. These treatments "routinely occurred" while neither Shah nor other physicians were present and, in one such instance, a patient experienced an adverse event requiring transport to hospital, according to the release.
Witness testimony also established that Shaw required patients to undergo diagnostic ultrasounds prior to ECP, in part to rule out blood clots, but did not review any of the images prior to approving new patients for ECP.
Contraindications to enhanced ECP include decompensated heart failure, severe peripheral artery disease, and severe aortic regurgitation, according to a 2014 multisociety focused update on stable ischemic heart disease (SIHD). It states that enhanced ECP "may be considered" for relief of refractory angina in patients with SIHD (class IIb evidence).
Shah double-billed insurers using a bundled ECP code, "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," the release says.
Between 2008 and 2013, Shah submitted ECP-related claims to Medicare, Medicaid, Highmark Blue Cross Blue Shield, UPMC Health Plan, and Gateway Health Plan beneficiaries totaling more than $13 million, for which he received payments in excess of $3.5 million.
"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," United States Attorney Scott W. Brady said in the release. "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."
Shah is to be sentenced November 6 and faces a maximum of 10 years in prison, a fine of $250,000, or both.