UPDATE, JUNE 21, 1:48 P.M.: Orange County Supervising District Attorney Investigator Dina Mauger is asking members of the public to call her office if they believe they were victims of a $17 million workers' compensation insurance overbilling scheme.
Newport Beach radiologist Dr. Sim
Carlisle Hoffman, owner of Advanced Professional Imaging
(API), Advanced Management Services (AMS), and Better Sleeping Medical
Center (BSMC) in Buena Park, is accused of running a “medical mill” for the sole purpose of
insurance overbilling without providing any legitimate treatment to any patients.
]
Last week, District Attorney Tony Rackauckas and California Insurance Commissioner Dave Jones announced the laundry list of charges against Hoffman as well as BSMC neurologist Dr. Michael Heric, Hoffman's administrator Beverly Mitchell and API billing collector Louis Santillan.
If you think you are a victim, call 714.648.3667. Since most victims were Spanish-speaking, here is the OCDA plea for victims to come forward en Espanol:
AVISO DE PRENSA
QUIEN: Supervisora Investigadora de la Fiscalía del Condado de Orange, Dina Mauger
NÚMERO DE CONTACTO: (714) 648-3667
QUE: Aceptara llamadas de personas que se consideren ser víctimas del
fraude de sobre-facturación de $17 millones al seguro de compensación
para trabajadores, cual involucra a dos doctores, un administrador, y un
asistente de colecciones de facturaciones. El doctor Sim Hoffman es un
radiólogo y dueño de los negocios Advanced Professional Imaging (API),
Advanced Management Services (AMS), y Better Sleeping Medical Center
(BSMC) en la ciudad de Buena Park. Junto con el doctor Michael Heric,
Beverly Mitchell, y Louis Santillan, son acusados de operar los negocios
como un “molino medico” con el único propósito de sobre-cobrar las
compañías de seguros sin realizar tratamientos legítimos a sus
pacientes.
Para leer todo sobre el caso contra Hoffman et al., por favor seleccione
el comunicado de prensa del 13 de junio del 2011, “Radiólogo,
Neurólogo, y Dos Cómplices Enfrentan Cargos en el Gran Jurado por Fraude
de Sobre-Facturación $17 Millones al Seguro de Compensación Para
Trabajadores” en la sección Press Releases/Media Advisories de
www.orangecountyda.com.
ORIGINAL POST, JUNE 13, 3:28 P.M.: You won't find Orange County District Attorney Tony Rackauckas, a staunch conservative, on the same side of many political debates with California Insurance Commissioner Dave Jones, a flaming liberal.
But there the two were in the OCDA law library in downtown Santa Ana this morning, standing side-by-side to explain their joint case against a Newport Beach radiologist and three of his workers accused of pulling off a $17 million workers' compensation insurance
over-billing scheme.
Grand jury transcripts unsealed this morning show that indictments were served May 11 on:
- Dr. Sim Carlisle Hoffman, a 59-year-old Newport Beach radiologist and owner
of Advanced Professional Imaging (API), Advanced Management Services
(AMS), and Better Sleeping Medical Center (BSMC) in Buena Park. He is
charged with 592 felony counts of insurance fraud for BSMC, 291 felony
counts of insurance fraud for API, and one felony count of aiding and
abetting the unauthorized practice of medicine. If convicted, he faces a
sentence ranging from two years up to 892 years and eight months in
state prison. Hoffman is out of custody on $1.5 million bail. In 2001,
Hoffman was disciplined by the Medical Board of California (Board) for
excessive billing and subjecting a patient to radiology procedures that
were not medically necessary.
- Beverly Jane Mitchell, 60, of Westlake Village and the administrator in
charge of insurance billing for all of Hoffman's businesses. She faces
the same charges and maximum sentence as Hoffman. Mitchell is out of
custody on $250,000 bail.
-
Dr. Thomas Michael Heric, a 74-year-old Malibu neurologist who worked for
Hoffman at BSMC. He is charged with 296 counts of insurance fraud and
one felony count of aiding and abetting the unauthorized practice of
medicine. If convicted, he faces a sentence ranging from two years up to
315 years and eight months in state prison. Heric is out of custody on
$500,000 bail. His medical license was suspended by the Board for 60
days as a result of a 2008 felony federal Medicare and Medi-Cal fraud
conviction.
- Louis Umberto Santillan, 44, of Chino Hills and a billing
collections worker for API. He is charged with 141 felony counts of insurance
fraud and faces a sentence ranging from two years up to 150 years in
state prison if convicted. Santillan is out of custody on $250,000 bail.
Santillan has no college degree or certification.
The four are scheduled to be arraigned June 22 in Santa Ana. A condition of Hoffman and Heric's bail is that they face the California Medical Board for license revocation proceedings.
One part of the alleged fraud involves an intricate medical procedure only two physicians in the state are licensed to perform, and neither of them work in Hoffman's facility. And yet, the state worker's comp insurer was billed by Hoffman's office for the painful procedure being performed on mostly Spanish-speaking patients, some as many as 20 times each.
That portion of the alleged fraud alone accounts for $9 million in over-billings. Authorities characterize 1,247 patient files as being “cookie cutter” and all signed by Heric.
Ironically, federal Judge David O. Carter had Hoffman's lawyers in his Santa Ana courtroom as soon as this past February. In Sim Hoffman, et al v. Zenith Insurance Company, the doctor alleged that his insurer violated the U.S. Racketeer Influenced and Corrupt Organizations Act (or RICO) by failing to pay off on some claims the carrier suspected were fraudulent. Carter ruled in favor of Zenith.
What follows after the break are Rackauckas' remarks from today which, more than anything, explain the alleged scam. That's followed by the OCDA statement on the indictments–in English and Spanish.
[
June 13, 2011
Remarks by District Attorney Tony Rackauckas
Hoffman et al. indictment
June 13, 2011
Thank you for coming.
We are honored to have with us Insurance Commissioner Dave Jones. We
are also joined in the audience by representatives from a number of
insurance companies. Thank you for being here. On May 11, 2011, the
grand jury returned a 181-page, 884-count indictment against doctors Sim
Hoffman and Thomas Heric, medical center administrator Beverly
Mitchell, and medical bill collector Louis Santillan.
Today is the first day the transcripts from those grand jury proceedings
are available to the public. This case is a massive workers'
compensation insurance fraud scheme involving over $17 million in
overbilling for unnecessary or never-performed procedures.
The mastermind of this medical mill is Dr. Sim Hoffman. Hoffman is a
radiologist who owns the sleep and nerve testing centers. He is charged
for using patients as props in order bilk the system by over-billing the
insurance companies. Dr. Hoffman was disciplined in 2001 by the Medical
Board of California for similar unethical medical practices.
Neurologist Thomas Heric was brought in by Hoffman to the sleep center
to “study” the patients and write reports on their status. Heric's
so-called “studying” of patients involved using a made-up formula,
entirely of his own creation, that is not recognized in any medical
community. Every single report written by Heric? Cookie cutter reports
on 1,247 patient files. Every patient? Diagnosed with a “disability,”
yet not one of those patients every received treatment.
In 2008, Heric's license was suspended for 60 days in 2008 for a felony
federal Medicare and medi-cal fraud conviction. After Hoffman was
disciplined in 2001, administrator Beverly Mitchell was brought in to
act as Hoffman's right hand. Instead of cleaning up his act, she helped
him expand his businesses and is charged for personally processing and
submitting the fraudulent billings.
Louis Santillan was hired as a bill payment collector. He has no college
degree and no certification. He is charged with knowing that Hoffman
was running a sham business and collecting $800,000 in commission from
fraudulent obtained money over two years.
This particular scheme was two-fold. First – Hoffman's sleep center,
which operated under the pretense of diagnosing and treating patients
with sleep disorders. To streamline the case, we sought an indictment on
acts occurring for only a one-year period from 2007 to 2008. Hoffman is
charged for billing for epilepsy and seizure testing on 1,247 patients
without ever conducting these tests on a single patient.
During this time period, not a single patient ever received any
treatment from the defendants for the supposed “disorders” Hoffman and
Heric diagnosed. For this part of the mill involving processing 1,247
patients, Hoffman is accused of billing exactly $6,728 to the insurance
company. This scheme resulted in over $8.4 million in fraudulent
billings.
Second – Hoffman's nerve testing center, Advanced Professional Imaging.
Patients were referred to him for “testing” as part of a worker's
compensation claim. Hoffman would perform an EMG test on them, which
should be billed at approximately $35 per test. Instead, Hoffman and
Mitchell are charged with billing insurance companies for Single Fiber
EMGs, which can be billed at $330 per procedure.
To give you some perspective, an EMG is a non-invasive, out-patient
procedure. A Single Fiber EMG on the other hand is an invasive, painful
procedure, often needing hospitalization to prevent bleeding and
infection. Single Fiber EMGs take an hour to perform and involve
sticking a giant needle into a single nerve. The needle tests for
electricity conduction. Only two doctors in California are qualified to
perform this test because it is so complex and requires specialized
training. Hoffman is not one of those two doctors. And Hoffman didn't
just bill for one Single Fiber EMG per patient. According to his bills,
the patients went through this painful procedure over 20 times each.
This scheme resulted in over $9 million in fraudulent billing. Most of
the patients were blue collar workers and the majority was
Spanish-speaking.
Let me talk to you about 56-year-old Jane Doe. After 30 years with the
same company, Jane Doe hurt her wrist and ankle by tripping over some
boxes at work. Through the referral of an attorney, Jane Doe was sent to
Hoffman's mill. On the conveyer belt, she underwent a sleep study, MRI,
and nerve testing. Jane Doe was never told the results of her
diagnostic tests. Months later, she was informed by her attorney that
her claim had been denied by the insurance company. Jane Doe, shut out
of her own case, was paid $5,900 cash, and told she could seek care in
Tijuana. She never received any treatment for her injuries.
Hoffman, on the other hand, is still to this day aggressively pursuing
payment of Jane Doe's fraudulent medical bills in the form of liens
amounting to over $15,000. Now multiply Jane Doe's case by over 1,200
patients. These patients were used as pawns in Hoffman's piggy bank.
The volume of this scheme leads to one reasonable conclusion – not
accidental, but intentional. Hoffman, Heric, Mitchell, and Santillan
created a $17 million medical mill at the expense of over 1,200 patients
and the workers' compensation insurance system. In Hoffman's analysis
assembly line, patient out, profit in. It is no secret that these types
of fraud are resulting in higher insurance rates and hemorrhaging
California businesses.
We need to end these types of medical fraud mills – STAT. Let's end
unethical doctors, unscrupulous dealings, and patients being treated
like walking ATMs. We hope before people engage in these types of
schemes, they ask themselves if this is worth 800 years in prison?
[
June 13, 2011
RADIOLOGIST, NEUROLOGIST, AND TWO CO-DEFENDANTS INDICTED IN $17 MILLION WORKERS' COMPENSATION INSURANCE OVERBILLING SCHEME
*Grand jury transcripts revealed for the first timeSANTA ANA – The Orange County District Attorney's Office (OCDA) and
California Department of Insurance (CDI) announced today the facts
surrounding the indictment of a radiologist, a neurologist, and two
co-defendants for a $17 million workers' compensation insurance
overbilling scheme. The indictments against the four defendants were
issued May 11, 2011, and the grand jury transcripts were unsealed today,
June 13, 2011.
“We need to end these types of medical fraud mills – STAT. Let's end
unethical doctors, unscrupulous dealings, and patients being treated
like walking ATMs,” stated District Attorney Tony Rackauckas. “We hope
before people engage in these types of schemes, they ask themselves if
this is worth 800 years in prison?”
“The magnitude of the fraud committed by these co-conspirators is
reprehensible,” said Insurance Commissioner Dave Jones. “When medical
providers conspire to defraud the California workers' compensation
insurance system, everybody loses, including the injured workers and the
businesses that employ them.”
This case was investigated by CDI and the OCDA. Deputy District Attorney
Shaddi Kamiabipour of the Workers' Compensation Fraud Unit is
prosecuting this case.
Defendants
Dr. Sim Carlisle Hoffman, 59, Newport Beach, is a radiologist and owner
of Advanced Professional Imaging (API), Advanced Management Services
(AMS), and Better Sleeping Medical Center (BSMC) in Buena Park. He is
charged with 592 felony counts of insurance fraud for BSMC, 291 felony
counts of insurance fraud for API, and one felony count of aiding and
abetting the unauthorized practice of medicine. If convicted, he faces a
sentence ranging from two years up to 892 years and eight months in
state prison. Hoffman is out of custody on $1.5 million bail. In 2001,
Hoffman was disciplined by the Medical Board of California (Board) for
excessive billing and subjecting a patient to radiology procedures that
were not medically necessary.Beverly Jane Mitchell, 60, Westlake Village, is the administrator in
charge of insurance billing for all of Hoffman's businesses. She faces
the same charges and maximum sentence as Hoffman. Mitchell is out of
custody on $250,000 bail.
Dr. Thomas Michael Heric, 74, Malibu, is a neurologist who worked for
Hoffman at BSMC. He is charged with 296 counts of insurance fraud and
one felony count of aiding and abetting the unauthorized practice of
medicine. If convicted, he faces a sentence ranging from two years up to
315 years and eight months in state prison. Heric is out of custody on
$500,000 bail. His medical license was suspended by the Board for 60
days as a result of a 2008 felony federal Medicare and Medi-Cal fraud
conviction.
Louis Umberto Santillan, 44, Chino Hills, worked for Hoffman in billing
collections for API. He is charged with 141 felony counts of insurance
fraud and faces a sentence ranging from two years up to 150 years in
state prison if convicted. Santillan is out of custody on $250,000 bail.
Santillan has no college degree or certification.
Prior to posting bail, all four defendants were required by the court to
prove their bail money was from a legal and legitimate source. All four
defendants are scheduled for continued arraignment June 22, 2011, at
8:30 a.m. in Department C-5, Central Justice Center, Santa Ana. Hearing
on the revocation of Hoffman and Heric's medical licenses as a
condition of bail will also be heard at that time.
Investigation
In January 2008, two BSMC employees filed a complaint with the
California Department of Health Services regarding unsanitary conditions
and lack of proper patient care at the facility. This complaint was
forwarded to Don Marshall, Vice President of the National Anti-Fraud
Program for Zenith Insurance Company (Zenith).Based on this complaint, Zenith began a fraud investigation into BSMC
and API and contacted CDI in July 2008. Zenith forwarded evidence that
BSMC was not conducting an appropriate medical business and was
overbilling for procedures that had no medical value or necessity.
CDI began investigating this case in July 2008 and turned over the case
to the OCDA in June 2010. Following an extensive, lengthy joint
investigation, the OCDA presented the case to the Orange County Grand
Jury in May 2011. All four defendants were indicted May 11, 2011.
Fault in the Workers' Compensation Insurance System
California employers are required by law to maintain workers'
compensation insurance for employees to provide medical services and
lost wage compensation in the event of an injury sustained at work.
Unlike other medical industries, doctors and insurance companies are not
required by law to communicate with the workers' compensation insurance
recipient/injured worker regarding what medical procedures are being
claimed for the purpose of billing. Consequently, there is no system in
place to verify which services were provided during a medical
appointment.As a result, unscrupulous medical providers are able to exploit the
workers' compensation system and injured worker by subjecting the
injured worker to unnecessary medical diagnostic tests in order to
generate higher insurance bills. These unethical medical providers are
also able to bill the insurance companies for services never rendered.
Profile of Injured Employees Targeted in Scheme
Employees injured on the job are entitled to file workers' compensation
claims to have their medical treatment covered by their employer's
insurance. In some cases, the injured workers hire attorneys when they
feel the insurance company is not adequately handling their claim. These
attorneys are responsible for communicating with the insurance company
on behalf of their client and often refer the injured worker to
chiropractors for treatment. The chiropractors frequently refer the
injured workers to other medical providers, often unnecessarily, for
diagnostic studies including sleep centers and nerve testing.In this case, the injured employees were primarily blue collar workers
in industries such as manufacturing, construction, or other fields
involving manual labor. The majority are Hispanic and many are
Spanish-speaking. All of these workers in this case were referred by
chiropractors or attorneys to API or BSMC.
In order to streamline the case, the OCDA chose to limit the charges to
600 patients and select time periods. In all of these cases (below), the
injuries to the worker could have been treated and fully resolved for
under $5,000. The defendants are accused of instead fraudulently billing
over $15,000 per patient.
API Overbilling Scheme
Hoffman is accused of opening API as a facility to perform Magnetic
Resonance Imaging. In order to generate extra billing, he is accused of
expanding to perform nerve testing called Electromyography (EMG), in
which muscle cells are analyzed for neurological activity. This is a
non-invasive, out-patient procedure that should be billed at
approximately $35 per test.Single Fiber EMG is an invasive, painful procedure that often requires
hospitalization and can result in bleeding and infections if not
performed properly. This test takes an hour to perform and involves
sticking a massive needle into a single nerve to detect damage based on
electricity conduction. This test is significantly more complex and
costly that can be billed at $330 per procedure. Most neurologists are
not qualified to perform this test based on the intense specialization
and training required. Only two doctors in California are qualified.
Between June 2007 and March 2009, Hoffman is accused of conducting an
EMG test on patients and overstating the nature of the test. Instead of
billing for the performed EMG, he is accused of fraudulently billing
insurance companies for Single Fiber EMGs.
Hoffman is accused of billing for Single Fiber EMGs as many as 20 times
per patient, despite this test never being rendered by Hoffman or any
physician employed at API on any patient. The defendant is accused of
inflating insurance billings from what should legitimately have been
under $2,000 to approximately $10,000 per patient.
After receiving payment from the insurance companies on the fraudulent
bills, Hoffman is accused of re-submitting the same bill as a lien
against the patient's workers' compensation insurance case in order to
collect additional payment.
Hoffman is accused of fraudulently billing seven insurance companies
including Berkshire Hathaway Homestate Companies, California State
Compensation Insurance Fund, Commercial Property and Casualty Insurance,
Fireman's Fund Insurance Company, Liberty Mutual, Travelers Insurance,
and Zenith.
In all, he is accused of billing insurance companies over $9 million in Single Fiber EMGs alone in the API scheme.
Sleep Center Overbilling Scheme
Hoffman is accused of opening BSMC in 2007 and failing to hire a
certified technician or a qualified physician to supervise the sleep
center, as required by law. A “sleep center” is a medical facility that
specializes in the diagnosis and treatment of patients suffering from
sleep disorders.Between November 2007 and November 2008, Hoffman is accused of filing
insurance claims for 1,247 patients. He is accused of billing for
epilepsy and seizure testing for all 1,247 patients without ever
conducting these tests on a single patient.
Hoffman is accused of paying Heric $100 per patient to write a report on
the patient's condition (see below). Despite all of the 1,247
“reports” indicating that the patient needed medical treatment, none of
the patients ever received medical treatment or care from BSMC.
In the course of the investigation it was determined that two of the
patients who underwent “testing” suffered severe sleep disorders and
were in dire need of medical attention. These disorders were neither
diagnosed nor treated at BSMC. During the grand jury proceedings,
medical experts opined that the service rendered to patients at BSMC was
a “disgrace” and had “no medical value.”
Hoffman is accused of operating this facility as a “medical mill” for
the sole purpose of insurance billing and without providing any
legitimate treatment to any of his patients. For all 1,247 patients,
Hoffman is accused of billing exactly $6,728 to the insurance company.
Hoffman is accused of fraudulently billing the City of Los Angeles and
19 insurance companies including Berkshire Hathaway Homestate Companies,
California State Compensation Insurance Fund, Chartis division of
American International Group, Commercial Property and Casualty
Insurance, Crum & Forster Holdings Corporation, Employers Insurance,
FirstComp Insurance, Fireman's Fund Insurance Company, The Hartford
Financial Services Group, Liberty Mutual, Matrix Direct Insurance
Services, Republic Indemnity Company of America, SeaBright Insurance
Company, Sentry Insurance, Specialty Risk Services, Travelers Insurance,
Southern California Risk Management Associates (now York Insurance
Services Group – California), Zenith, and Zurich Financial Services
Group.
By November 2008, he is accused of billing insurance companies over $8.4 million in the BSMC scheme.
Role of Hoffman's Co-defendants
As a result of Hoffman's 2001 Board discipline, he is accused of hiring
Mitchell to manage all billing and administration for his businesses
through AMS as part of his rehabilitation. Mitchell is accused of
knowing that Hoffman had been disciplined by the Board and helping him
to continue his fraudulent scheme. She is accused of directly
supervising all fraudulent billing from API and BSMC to the insurance
companies knowing that the procedures were overstated or never
performed. Mitchell is also accused of “unbundling,” or breaking up
procedures and billing them separately instead of together with the
intention of fraudulently collecting higher payments.Heric is a neurologist and is associated with Hoffman from several years
ago. He was convicted in 2008 of felony federal fraud, for which his
medical license was suspended by the Board for 60 days. In exchange for
$100 per patient, Heric is accused of writing “reports” on all 1,247
sleep center patients evaluating the data generated during their sleep
study. He is accused of finding in his “reports” that all 1,247
patients were “disabled” by using a formula entirely of his own
invention not recognized in the medical community to reach his
conclusions. None of these patients ever received any treatment for
their supposed disability. All of his reports on the 1,247 patients are
almost identical. Heric's reports were used to lend legitimacy to the
fraudulent insurance bills for each patient.
Santillan is accused of supervising the collections department for
Hoffman's businesses and collecting payment on the medical bills knowing
they were inflated and fraudulent. He is accused of receiving
approximately $800,000 in commission on all of the fraudulent monies
collected for Hoffman between 2006 and 2007.
[
13 de junio, 2011
RADIÓLOGO, NEURÓLOGO, Y DOS CÓMPLICES ENFRENTAN CARGOS EN EL GRAN JURADO
POR FRAUDE DE SOBRE-FACTURACIÓN $17 MILLONES AL SEGURO DE COMPENSACIÓN
PARA TRABAJADORES
* Las transcripciones del gran jurado fueron hechas públicas por la primera vezSANTA ANA – La Oficina del Fiscal del Condado de Orange (OCDA) y el
Departamento de Seguros de California (CDI) anunciaron hoy los hechos
sobre un radiólogo, neurólogo, y dos cómplices que enfrentan cargos en
el gran jurado por un fraude de sobre-facturación de $17 millones al
seguro de compensación para trabajadores. Las acusaciones formales
contra los cuatro acusados fueron iniciadas el 11 de mayo del 2011, y
las transcripciones del gran jurado fueron hechas públicas hoy, el 13 de
junio del 2011.“Necesitamos suprimir este tipo de “molino medico” fraudulento – YA.
Detengamos los doctores sin ética, los acuerdos sin escrúpulos, y el
tratamiento de pacientes como si fueran cajeros automáticos,” dijo el
Fiscal Tony Rackauckas. “Esperamos que antes de que la gente se
involucre en este tipo de fraude, se pregunten si vale una sentencia de
800 años en prisión.”“La magnitud de este fraude cometido por estos acusados es reprensible,”
dijo el Comisionado del Departamento de Seguros Dave Jones. “Cuando
médicos conspiran estafar el sistema de seguro de compensación para
trabajadores, todos pierden, incluyendo los empleados heridos y los
negocios por quienes trabajan.”Este caso fue investigado por CDI y el OCDA. El caso será procesado por
la fiscal asistente Shaddi Kamiabipour de la Unidad de Fraude en
Compensación Para Trabajadores.Acusados
Doctor Sim Carlisle Hoffman, 59, de la ciudad de Newport Beach, es un
radiólogo y dueño de los negocios Advanced Professional Imaging (API),
Advanced Management Services (AMS), y Better Sleeping Medical Center
(BSMC) en la ciudad de Buena Park. Él es acusado de 592 cargos de
delitos graves por fraude de seguros por BSMC, 291 cargos de delitos
graves por fraude de seguros por API, y un cargo de delito grave por
prestar auxilio y ayuda en practicar medicina no autorizada. Si lo
condenan, él enfrentará una sentencia entre dos años hasta 892 años y
ocho meses en prisión estatal. Hoffman esta libre bajo fianza de $1.5
millón. En el 2001, Hoffman fue disciplinado por la Mesa Directiva de
Medicina en California (Mesa Directiva) por cobrar en exceso y someter a
pacientes a exámenes de radiología que no eran medicamente necesarios.Beverly Jane Mitchell, 60, de la ciudad de Westlake Village, es la
administradora encargada con la facturación de seguros para todos los
negocios de Hoffman. Ella enfrenta los mismos cargos y sentencia máxima
que Hoffman. Mitchell está libre bajo fianza de $250,000.Doctor Thomas Michael Heric, 74, de la ciudad de Malibu, es un neurólogo
que trabajó para Hoffman en BSMC. Él es acusado de 296 cargos de
delitos graves por fraude de seguros, y un cargo de delito grave por
prestar auxilio y ayuda en practicar medicina no autorizada. Si lo
condenan, él enfrentará una sentencia entre dos años hasta 315 años y
ocho meses en prisión estatal. Heric está libre bajo fianza de $500,000.
Su licencia médica fue suspendida por la Mesa Directiva por 60 días
gracias a una convicción en el 2008 por fraude federal contra Medicare y
Medi-Cal.Louis Umberto Santillan, 44, de la ciudad de Chino Hills, trabajó para
Hoffman en colecciones de facturación para el API. Él es acusado de 141
cargos de delitos graves por fraude de seguros, y enfrentará una
sentencia entre dos años hasta 150 años en prisión estatal si es
condenado. Santillan está libre bajo fianza de $250,000. Santillan no
tiene un titulo de universidad o certificación.Antes de salir libre bajo fianza, la corte requiere que los cuatro
acusados den prueba de que el dinero para pagar la fianza viene de una
fuente legitima y legal. Se espera que los cuatro acusados sean
instruidos de los cargos el 22 de junio del 2011, a las 8:30 de la
mañana, en el departamento C-5, en la Corte Central de la ciudad de
Santa Ana. También tendrán la audiencia para la revocación de las
licencias médicas de Hoffman y de Heric como condición de la fianza en
ese entonces.Investigación
En enero del 2008, dos empleados de BSMC registraron una queja con el
Departamento de Servicios de Salud en California con respecto a las
condiciones antihigiénicas y la falta de cuidado apropiado de los
pacientes en la clínica. La queja fue remitida a Don Marshall, el vice
presidente del Programa Antifraude Nacional para la compañía de seguros,
Zenith Insurance Company (Zenith).De acuerdo con esta queja, Zenith comenzó a investigar fraude dentro los
negocios BSMC y API, y se puso en contacto con CDI en julio 2008.
Zenith les remitió evidencia mostrando que BSMC no dirigió un negocio
médico apropiado y que cobro excesivamente por procedimientos que no
tenían valor o necesidad médica.CDI comenzó a investigar este caso en julio del 2008 y entregó el caso
al OCDA en junio del 2010. Después de una investigación común, larga y
extensa, el OCDA presento el caso al Gran Jurado del Condado de Orange.
Los cuatro fueron acusados formalmente el 11 de mayo del 2011.Fallas En El Sistema De Seguro De Compensación Para Trabajadores
La ley de California requiere que los empleadores mantengan el seguro de
compensación para trabajadores para ofrecer servicios médicos y
compensación de sueldo perdido si se sufre un accidente en el trabajo.
Distinto a otras industrias médicas, la ley no requiere que los doctores
y las compañías de seguros se comuniquen con el beneficiario/empleado
herido del seguro de compensación para trabajadores con respecto a qué
procedimientos médicos se está registrando para la facturación. Por lo
tanto, no hay un sistema en lugar para verificar qué servicios fueron
proporcionados durante una cita médica.Consecuentemente, los médicos sin escrúpulos pueden aprovecharse del
sistema del seguro de compensación para trabajadores y el empleado que
sufrió un accidente, al someterlo a pruebas médicas innecesarias para
generar facturas más costosas. Estos médicos inmorales pueden también
someter facturas a las compañías de seguros para servicios que nunca
fueron realizados.Perfil de Empleados Heridos Escogidos Para el Fraude
Empleados heridos mientras están trabajando tienen el derecho de
registrar una demanda del seguro de compensación para trabajadores para
recibir tratamiento médica, cubierto por el seguro del empleador. En
algunos casos, el empleado herido contrata a un abogado cuando siente
que la compañía de seguros no está manejando adecuadamente su demanda.
Estos abogados son responsables de comunicarse con la compañía de
seguros a nombre de su cliente y, a menudo, refieren al empleado herido a
un quiropráctico para recibir tratamiento. Los quiroprácticos refieren
al empleado herido, con frecuencia, a otros médicos en clínicas de sueño
y pruebas de los nervios, muchas veces innecesariamente, para estudios
diagnósticos.En este caso, muchos de los empleados heridos son trabajadores de collar
azul en industrias de fabricación, construcción, u otros campos de
trabajo manual. La mayoría de los empleados son Latinos y muchos de
ellos solo hablaban español. Todos los empleados, en este caso, fueron
referidos a API o BSMC por quiroprácticos o abogados.Para poder manejar el caso, el OCDA decidió limitar los cargos
criminales a 600 pacientes, durante una temporada específica, y no
incluye la conducta criminal completa. En todos estos casos (favor de
ver abajo), las heridas del empleado se habrían podido curar por menos
de $5,000. En vez, los cuatro son acusados de registrar facturas de más
de $15,000 por paciente.Fraude de Sobre-Facturación por API
Hoffman es acusado de establecer el negocio API como una clínica para
realizar exámenes de Proyección de Imagen de Resonancia Magnética. Para
generar facturas adicionales, él es acusado de expandir el negocio para
también realizar pruebas de los nervios llamada Electromiografía (EMG),
utilizada para analizar actividad neurológica de las células musculares.
Este procedimiento que solo debe costar aproximadamente $35 por examen,
no es invasivo ni se necesita ser internado.EMG de Fibra Singular es un examen invasivo y doloroso que por la mayor
parte requiere ser realizado en un hospital, y, que puede dejar al
paciente sangrando o con infecciones si no se realiza correctamente.
Este examen toma una hora e incluye meter una aguja enorme dentro un
solo nervio para detectar daño atreves de conducción eléctrico. Es un
examen mucho más sofisticado y complejo que puede ser facturado a $330
por examen. Muchos neurólogos no son calificados para realizar este
examen, a base de que se requiere entrenamiento y es una especialización
intensa. En el estado de California, solo dos doctores son calificados.Entre junio del 2007 y marzo del 2009, Hoffman es acusado de conducir
exámenes EMG con pacientes y exagerando la necesidad de los exámenes. En
vez de cobrar por el EMG realizado, él es acusado de mandar
facturaciones fraudulentas a compañías de seguro por exámenes EMG de
Fibra Singular.Hoffman es acusado de facturar cuentas por EMG de Fibra Singular, 20
veces por cada paciente, aunque el examen nunca fue realizado por
Hoffman u otro médico asistente de API. Él es acusado de inflar las
cuentas que registró con las compañías de seguros que legítimamente
pudieron ser $2,000 a alrededor de $10,000 por paciente.Después de recibir pago del las compañías de seguros para las facturas
fraudulentas, Hoffman es acusado de registrar de nuevo la misma factura
como un embargo contra el seguro de compensación de trabajadores del
paciente para sacar pagos adicionales.Hoffman es acusado de mandar facturas fraudulentas a siete compañías de
seguros incluyendo a Berkshire Hathaway Homestate Companies, California
State Compensation Insurance Fund, Commercial Property and Casualty
Insurance, Fireman's Fund Insurance Company, Liberty Mutual, Travelers
Insurance, y Zenith.En total, él es acusado de cobrar a compañías de seguros más de $9
millones solo por el examen de EMG de Fibra Singular en el fraude de
API.Fraude de Sobre-Facturación de la Clínica de Sueño
Hoffman es acusado de establecer BSMC en el 2007 y de no contratar un
técnico certificado o un medico calificado para supervisar la clínica
de sueño, según los requisitos de la ley. Una “clínica de sueño” es una
clínica que especializa en el diagnosis y tratamiento de pacientes que
sufren desordenes de sueño.Entre noviembre del 2007 y noviembre del 2008, Hoffman es acusado de
registrar reclamaciones de seguro para 1,247 pacientes. Él es acusado de
cobrar por exámenes de epilepsia y asimiento para todos los 1,247
pacientes sin conducir estos exámenes con ningún paciente.Hoffman es acusado de pagarle a Heric $100 por paciente, para que
escriba un reporte sobre la condición del paciente (favor de ver abajo).
Aunque todos los 1,247 “reportes” indicaron que el paciente necesitaba
tratamiento médico, ninguno de los pacientes recibió tratamiento o
atención medica de BSMC.Durante el curso de la investigación, se determino que dos de los
pacientes que fueron sometidos a “exámenes” estaban sufriendo un
desorden severo de sueño y estaban en grave necesidad de atención
médica. Estos trastornos no fueron diagnosticados, ni fueron tratados
por BSMC. Durante los procedimientos del gran jurado, expertos médicos
opinaron que los servicios para pacientes de BSMC eran una “vergüenza”
sin “ningún valor medico.”Hoffman es acusado de operar este negocio como un “molino medico” con el
único propósito de cobrar las compañías de seguros sin realizar
tratamientos legítimos a sus pacientes. Por los 1, 247 pacientes,
Hoffman es acusado de cobrar exactamente $6,728 a las compañías de
seguros.Hoffman es acusado de mandar facturas fraudulentas a la Ciudad de Los
Angeles y 19 compañías de seguros incluyendo a Berkshire Hathaway
Homestate Companies, California State Compensation Insurance Fund,
Chartis Division of American International Group, Commercial Property
and Casualty Insurance, Crum & Forster Holdings Corporation,
Employers Insurance, FirstComp Insurance, Fireman's Fund Insurance
Company, The Hartford Financial Services Group, Liberty Mutual, Matrix
Direct Insurance Services, Republic Indemnity Company of America,
SeaBright Insurance Company, Sentry Insurance, Specialty Risk Services,
Travelers Insurance, Southern California Risk Management Associates
(ahora York Insurance Services Group – California), Zenith, y Zurich
Financial Services Group.Para noviembre del 2008, él es acusado de cobrar a compañías de seguros más de $8.4 millones en el fraude de BSMC.
Papel de los Cómplices Acusados con Hoffman
Como parte de la disciplina de Hoffman por la Mesa Directiva, en el
2001, Hoffman es acusado de contratar a Mitchell para que arregle y
maneje la administración y las facturaciones por todos sus negocios
atreves de AMS para mostrar su rehabilitación. Mitchell es acusada de
estar enterada de que Hoffman fue disciplinado por la Mesa Directiva, y
ayudándolo a continuar su fraude. Ella es acusada de directamente
supervisar todas las facturaciones de API y BSMC a las compañías de
seguros, sabiendo que procedimientos fueron exagerados o nunca fueron
realizados. Mitchell también es acusada de “separar” procedimientos para
cobrarlos separadamente en vez de todo a la misma vez, con la intención
fraudulenta de recibir pagos más altos.Heric es un neurólogo y era socio de Hoffman hace varios años. Lo
condenaron en el 2008 de fraude federal grave, para el cual su licencia
médica fue suspendida por la Mesa Directiva por 60 días. A cambio de
$100 por paciente, Heric es acusado de escribir “reportes” sobre los
1,247 pacientes de la clínica de sueño como una evaluación de los datos
generados durante su estudio de sueño. Él es acusado de concluir en sus
“reportes” que los 1,247 pacientes eran “discapacitados” usando una
fórmula por entero de su propia invención, no reconocida en la comunidad
médica, para alcanzar sus conclusiones. Ningunos de estos pacientes
recibieron tratamiento para sus supuestas incapacidades. Todos sus
reportes sobre los 1,247 pacientes son casi idénticos. Los reportes de
Heric fueron utilizados para prestar legitimidad a las cuentas de seguro
fraudulentas para cada paciente.Santillan es acusado de supervisar el departamento de colecciones para
los negocios de Hoffman y de recibir pago de las facturas médicas
sabiendo que las facturas eran desorbitadas y fraudulentas. Él es
acusado de recibir aproximadamente $800,000 en comisiones de todo el
dinero coleccionado en manera fraudulenta para Hoffman entre 2006 y
2007.
OC Weekly Editor-in-Chief Matt Coker has been engaging, enraging and entertaining readers of newspapers, magazines and websites for decades. He spent the first 13 years of his career in journalism at daily newspapers before “graduating” to OC Weekly in 1995 as the alternative newsweekly’s first calendar editor.