Fox Chapel Cardiologist Sentenced to 78 Months in Prison for Health Care Fraud Scheme Involving More Than $13 Million of Insurance Billings

PITTSBURGH – A resident of Fox Chapel, Pennsylvania, was sentenced in federal court following his conviction at trial on two counts of health care fraud, Acting United States Attorney Stephen R. Kaufman announced today.

United States District Judge David S. Cercone sentenced Samirkumar J. Shah, 58, to 78 months of imprisonment followed by three years of supervised release.

“Dr. Shah risked the health of his patients so he could make millions of dollars through unnecessary procedures, and lied and fabricated records for years to perpetuate his fraud scheme,” said Acting U.S. Attorney Kaufman. “This prosecution demonstrates our commitment to protect the healthcare system from fraud and sends a clear message of deterrence to others who might consider similar criminal behavior.”

“Today’s sentence holds Mr. Shah accountable for his appalling actions,” said FBI Pittsburgh Special Agent in Charge Mike Nordwall. “Mr. Shah used his position as a doctor to illegally profit from a healthcare program paid for by taxpayers. Fraud of this magnitude will not be tolerated. The FBI, along with our partners, are committed to making sure the integrity of our health care benefit programs remains intact and will always work diligently to investigate and hold accountable those who think they can steal from the system.”

“Rather than upholding the oath he swore and providing care for patients who trusted him, this defendant misled patients and drained critical Medicaid funds from families who needed it,” said Attorney General Josh Shapiro. “We will not let anyone put their patients’ lives at risk for a profit.”

Shah was convicted on June 14, 2019, following an eight-day jury trial in Pittsburgh. The evidence introduced at trial established that between 2008 and 2013, Shah, a practicing cardiologist, submitted fraudulent claims to private insurance plans—Highmark Blue Cross Blue Shield (Highmark), UPMC Health Plan (UPMC)—as well as government insurance programs—Medicare and Medicaid (through Gateway Health Plan)—for an outpatient treatment known as external counterpulsation, or ECP. ECP involves the use of a specialized bed equipped with pressure cuffs, which exert pressure to patients’ lower extremities as a means to increase blood flow to the heart. The evidence at trial further demonstrated that insurers only reimbursed for ECP treatments of patients who suffered from disabling angina—or significant chest pain caused by decreased blood flow to the heart—and only when a physician supervised the treatment.

In total, Shah purchased 25 beds and offered ECP to patients at more than 18 locations in Western Pennsylvania, Ohio, New York, and Florida. The evidence also showed that, in order to acquire new patients, Shah advertised ECP as “the Fountain of Youth,” claimed that it made patients “younger and smarter,” and offered the treatment for a range of ailments other than disabling angina, including obesity, migraines, high blood pressure, low blood pressure, diabetes, and erectile dysfunction. 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.

The evidence also showed that patients were required to undergo certain diagnostic ultrasounds as a precautionary measure prior to starting ECP—in part to rule out blood clots that could cause a stroke or heart attack during the treatment. Nevertheless, witness testimony established that Shah did not review any of the ultrasound imagery before approving new patients to begin ECP, placing his patients at risk of serious injury or even death.

Likewise, contrary to health insurance requirements, ECP treatments routinely occurred while neither Shah nor any other medical doctor was present at his various locations. On one such occasion, a patient experienced an adverse event during his ECP treatment and had to be transported via ambulance to the hospital.

In addition to billing for ECP treatments that were not medically necessary and were not provided under direct physician supervision, Shah also double-billed insurers by using a so-called “bundled” ECP code, which accounted for and included payment for various incidental procedures, and then separately submitting claims for the same included procedures. The evidence at trial further established that during reviews initiated by various insurers, 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.

During the period of Shah’s scheme, the evidence showed that he submitted ECP-related claims for Medicare Part B, UPMC, Highmark, and Gateway beneficiaries, totaling more than $13 million and that he received reimbursement payments in excess of $3.5 million.

As part of his sentence, Shah must pay restitution totaling over $1.2 million to the victim insurers, as well as a $500,000 forfeiture money judgment.

Shah failed to appear for his original sentencing date on July 14, 2021, and he has been custody since the following day after Judge Cercone issued a warrant for his arrest.

Assistant United States Attorneys Eric G. Olshan and Nicole Vasquez Schmitt prosecuted this case on behalf of the government.

The Federal Bureau of Investigation and Pennsylvania Office of Attorney General, Medicaid Fraud Control Unit, conducted the investigation that led to the conviction of Shah.

 

 

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