“My dog ate my homework,” said Billy.

Sobbing, Sally said, “my grandma died, so I didn’t have time to write the paper.”

Maybe those excuses worked in fourth grade, and maybe Samirkumar J. Shah, M.D. should have tried them, but the one he went with, “I can’t show up at my sentencing for health care fraud because my doctor says I need to rest at home following a Covid vaccine reaction,” didn’t impress United States District Judge David S. Cercone.

The Background

Dr. Shah, a cardiologist, was convicted in June 2019 of two counts of health care fraud resulting from his submission of fraudulent claims to private insurance plans covered by Highmark Blue Cross Blue Shield and UPMC Health Plan, to managed Medicaid plans issued by Gateway Health Plan, as well as to Medicare, all in connection with outpatient external counterpulsation, also referred to as “ECP” treatment.

Payors cover ECP only for patients who suffer from disabling angina, and only when a physician supervises the treatment.

Yet Shah advertised ECP as the fountain of youth and claimed that it made patients younger and smarter. He offered the treatment for a range of ailments other than disabling angina, including, among others, obesity, high blood pressure, low blood pressure, and erectile dysfunction.

To support false claims, he instructed employees at his more than 18 locations to indicate on billing sheets that every patient had disabling angina. In many cases, neither he nor any other physician was present at the location when treatments were performed.

As if billing for medically unnecessary and unsupervised ECP treatments weren’t enough, Shah also double-billed insurers by billing for both a “bundled” ECP code, which accounted for and included payment for various incidental procedures, and then separately submitting claims for the same included procedures.

In addition, 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.

Time, or Not, to Pay the Piper

Between his June 2019 conviction and July 2021, Shah remained free, awaiting sentencing. Yes, the wheels of justice turn slowly, but eventually even that bus reaches its destination.

Facing a July 14, 2021, sentencing, Shah’s attorney made a motion that same day to continue the inevitable based on the claim that Shah’s doctor told him he needed six weeks bed rest due to an allergic reaction to the Covid vaccine.

Likely to no one’s surprise, the motion was denied and when Shah still didn’t show up for sentencing, the judge issued an order for his arrest. He remained in jail until August 5, 2021, when he was sentenced to 78 months of imprisonment followed by three years of supervised release as well as ordered to pay restitution of over $1.2 million to the victimized payors, in addition to forfeiting another $500,000.

Some Lessons

In addition to the serious slice of schadenfreude sprouting from the Shah story, you’d be well advised to note that most physicians engaging in billing fraud do so on a smaller scale than the industrial-sized health care fraud overseen by Shah. However, it’s just as illegal.

Billing for unnecessary tests and procedures, even on a small scale, is particularly egregious because of the risk inherent to the victim patients, let alone the financial fraud on payors.

Shah went down because of what appears to be an initial investigation by the Pennsylvania Attorney General’s Medicaid Fraud Control Unit. Often, physicians engaging in such scams are tripped up by someone within their office or at an outsourced billing and collection service who becomes a whistleblower, whether in the context of a false claims act lawsuit which then triggers a criminal investigation, or as an anonymous “tipster.”

If you can’t do the time, don’t do the crime.