A Newport Beach, Calif.-based radiologist and neurologist stand accused of orchestrating a $17 million workers' compensation insurance fraud scheme, according to the California Department of Insurance (CDI).
In the fraud scheme Radiologist Dr. Sim Carlisle Hoffman performed unnecessary tests and then billed insurers for much more extensive and costly exams. Hoffman owned and operated three separate medical facilities that provided MRI services. To generate extra billing, Hoffman allegedly ordered patients to undergo additional nerve testing called electromyography of EMG exams. EMGs are a non-invasive, out-patient test to examine muscle cells for neurological activity. Those tests typically cost $35, according to CDI.
But according to the indictment reported by Insurance News Net, Hoffman allegedly billed insurers for a different type of test known as a single-fiber EMG, which is an invasive, painful procedure that can often require hospitalization. Single-fiber EMG tests, which only two doctors in California are licensed to perform, typically cost $330. What raised red flags is that Hoffman allegedly billed insurers for as many as 20 single-fiber EMGs per patient -- causing cases that should have cost insurers less than $2,000 to exceed $10,000 per patient.
Hoffman is accused of defrauding several insurers in the scheme including Berkshire Hathaway Homestate Cos., California State Compensation Insurance Fund, Commercial Property and Casualty Insurance, Fireman's Fund Insurance Co., Liberty Mutual, Travelers Insurance, and Zenith Insurance Co.
In all, the indictment charges Hoffman with 592 felony counts of insurance fraud from his time as the owner of Better Sleeping Medical Center, and 291 additional counts of insurance fraud for his time as the owner of a separate facility, Advanced Professional Imaging.
The indictment also names as defendants Dr. Thomas Heric, a neurologist who is charged with 296 counts of felony insurance fraud and one count of aiding and abetting the unauthorized practice of medicine; Beverly Mitchell, the administrator of all of Hoffman's billing who faces the same charges as Hoffman; and Louis Santillan, who worked in billing collections for Hoffman and faces 141 felony counts of insurance fraud.
If convicted, Hoffman and Mitchell face a maximum sentence of 892 years in state prison; Heric faces up to 315 years; and Santillan faces up to 150 years.
Comments
This reads like another setup by an a bunch of insurance companies that just aren’t willing to pay claims, leaving patients high and dry while villifying the health professionals who have to live by “their rules”.
Was this doctor really breaking the law? Or is this simply a witch hunt that makes “good press” instigated by Zenith Insurance whose CEO, by the way, is listed as the 4th highest paid executive in Orange County?
And what about an ascertion that Zenith provides approximately 30% of the budget for the OC District Attorney’s Office? That would appear to be an interesting association and plenty of reason for the DA to pursue whatever the deep pockets of the insurance company would dictate.
Think about it.
When does this go to court ? I know one of the Dr’s in this scam and would like to see him burn for many, many years.