S. TEXAS DOCTORS AGREE TO PAY $5 MILLION TO SETTLE FALSE CLAIMS

U.S. Attorney's Office, Southern District of Texas

BROWNSVILLE, Texas - Six South Texas doctors and their respective practices have agreed to pay $4,855,844 to resolve allegations they submitted false claims to Medicare, Medicaid and TRICARE that were not rendered or not medically necessary, announced U.S. Attorney Nicholas J. Ganjei.

Drs. Javier Cabello, 47, San Benito, Ammar Halloum, 52, Brownsville, Jamil Madi, 54, Olmito, Jairo Rodriguez, 62, Rancho Viejo, Ricardo Schwarcz, 57, Weslaco, and Stanley Sy, 55, Pharr, owned and operated Benchmark Inpatient Services PLLC dba Beyond Inpatient Services in Harlingen. Rodriguez also owned and operated Brownsville Pulmonary Center, P.A. dba Benchmark Pulmonary Center, Brownsville.

From Jan. 1, 2020, to May 31, 2023, BIS, BPC, and its owners allegedly submitted claims for critical care, while BPC and Rodriguez also allegedly submitted claims for pulmonary function testing. Patients’ medical records allegedly did not support this care and testing, or the care was not rendered at all.

Critical care billing requires complex decision-making and at least 30 minutes of treatment for a critically ill or injured patient. BIS providers instead billed critical care for stable patients, unnecessary follow-up visits, or services they never performed, according to the allegations.

PFT services include various tests that demonstrate how well the lungs function. When medically necessary, PFT services either diagnose and evaluate new respiratory symptoms or assess a patient’s current therapeutic respiratory interventions. Medicare does not reimburse for routine PFT services. For Medicare to reimburse for medically necessary PFT services, providers must describe the indications and presentments for the order for testing in the patient’s medical record. BPC and Rodriguez instead allegedly billed PFT services for unnecessary routine testing or services they never performed.

As a result, Medicare, Medicaid, and TRICARE either paid significantly more for critical care claims or for PFT claims that should never have even been made to the government programs.

“This outcome emphasizes the Southern District of Texas’s commitment to vigorously investigate and disrupt civil health care fraud, wherever it may be,” said Ganjei. “Our country’s most vulnerable deserve care based on their medical need, not on a doctor’s unscrupulous desire to line their own pockets. Medical professionals have a solemn obligation to heal the sick and infirm, not to bilk the American taxpayer.”

“We remain steadfast in our mission to protect patients and safeguard federal health care programs,” said Special Agent in Charge Jason E. Meadows of the Department of Health and Human Services - Office of Inspector General. “This settlement underscores our commitment to holding providers accountable when they submit claims for services that are not medically necessary or not actually provided. We will continue to work closely with our law enforcement partners to ensure that taxpayer-funded programs are protected from fraud and abuse.”

“Fraud against the government will not be tolerated,” said Acting Special Agent in Charge Alex Doran of the FBI San Antonio Field Office. “Submitting false claims to federal health care programs during a national emergency such as the COVID 19 pandemic steals from taxpayers and exploits vulnerable patients. The FBI, together with its federal and state partners, will hold accountable anyone who seeks to profit by defrauding the United States.”

The settlement stems from a qui tam or whistleblower complaint filed under the False Claims Act which permits a private party to file an action on behalf of the United States and receive a portion of any recovery.

DHHS-OIG and FBI conducted the investigation with assistance from Defense Criminal Investigative Service and Texas Attorney General’s Office – Civil Medicaid Fraud Division. Assistant U.S. Attorney Laura E. Collins handled the matter.