Sunday, March 29, 2009 | 2 a.m.
Abuse under foreign doctor program alleged
When he started working for Dr. Dhiresh Joshi in February 2006, Dr. Fadi El Salibi was a “J-1 doctor,” a participant in a government program to bring foreign physicians to medically needy communities.
A lengthy Sun investigation in 2007 showed that many employers in Nevada were abusing the J-1 program by hiring doctors under the pretense of employing them in clinics in underserved areas, and instead assigning them to hospitals, where they could bring in more money for the boss.
El Salibi claims that Joshi forced him to work 100 hours a week and tried to pressure him to see up to 70 patients a day at multiple hospitals until his J-1 term ended in October 2007. He said he worked himself to exhaustion just seeing 40 to 50 patients a day, working every day of the week and being on call on the phone every night.
Other infectious disease specialists say it’s virtually impossible to see more than about 30 patients a day.
J-1 doctors are required by federal law to work at least 40 hours a week in a clinic in a medically underserved area. Elizabeth Neubauer, Joshi’s former billing manager, said Joshi rented space in the clinic of another doctor and the staff there kept a bogus schedule for El Salibi, complete with false patient names, in case state inspectors came calling.
El Salibi said he put in an appearance two mornings a week at the clinic where he was supposed to work. Meanwhile, Joshi assigned him to hospitals throughout Las Vegas. He said he was afraid state health officials would find out he was violating the terms of his agreement with the government, but they never came to the clinic.
Joshi said he never broke any of the rules that guided the J-1 program and said that El Salibi was always free to find other employment.
El Salibi, who now works on his own, said he can speak freely about his J-1 experience now because his immigration status is secure.
As she sat by her hospitalized husband — all day, day after day — Raye Kraft noticed how certain doctors would stop for a moment at his door and then head to the nurses’ station, writing notes about his condition in his medical chart.
Being the curious wife, she read the chart after the doctors left. Time and time again, she said, the two particular doctors — infectious disease specialists Dr. Dhiresh Joshi and his then-employee, Dr. Fadi El Salibi — wrote that they had examined her husband.
But she knew they often hadn’t set foot into his room.
So the 73-year-old woman started keeping closer tabs of how the doctors were caring for her husband, Eugene, a retired postal worker who is now deceased. They were, after all, billing his government insurance program for each exam.
She kept detailed notes every time she saw the doctors bypass the room and then write notes in Eugene’s chart. Then she read the doctors’ notes, which indicated they had examined her husband. Later, she reviewed the insurance bills submitted by the doctors.
Her claim: that on an ongoing basis, Joshi and El Salibi were writing in the chart that they had examined her husband when they hadn’t, and then billing for it. One supposed exam was nothing more than the doctor’s friendly wave from the door, she said.
She packaged up her allegations and sent them in a complaint to the Nevada Medical Examiners Board.
Unknown to her, Phil Nevins, the husband of another patient at HealthSouth Tenaya, a long-term acute care hospital, had complained a year earlier to the medical board of similar experiences. He said that the two infectious disease doctors were claiming to have given physical exams to his wife when they hadn’t. El Salibi and Joshi acknowledged being investigated for the complaints by Kraft, and the one by Nevins, which was dismissed.
The medical board does not comment on ongoing investigations or those that do not result in discipline.
Independent of the patients’ spouses, growing suspicions by nurses at MountainView Hospital Medical Center about El Salibi’s fly-by visits led to two additional complaints to the state medical board.
A July 3, 2007, complaint by one of the nurses says El Salibi “wrote progress notes with details of physical examinations without doing an examination on any of these patients.”
A different nurse at that hospital told the Sun that El Salibi would write his remarks in a patient chart based on the nurse’s evaluation of the patient, not his own. The nurse also complained to the medical board.
El Salibi acknowledged he is also being investigated for his treatment of 11 other patients at MountainView Hospital Medical Center.
“It is alleged you would enter these patients’ rooms, make notations in their charts, and then leave the rooms without examining the patients,” the medical board’s letter said. “It is further alleged you did not provide any medical care to these patients.”
Hospital officials said they could not comment on the matter.
El Salibi provided a letter to the Sun from the wife of one of the 11 patients who characterized his bedside manner as extraordinarily good.
Joshi’s former billing manager told the Sun she grew suspicious of his medical practices when she worked for him between 2001 and 2006. Elizabeth Neubauer, who now lives in Texas, said that Joshi himself routinely billed for 70 patients a day. Other infectious diseases doctors say that’s double the number they could reasonably see in a long day of hospital rounds.
Indeed, a 2004 Medicare audit showed that in a single day, Joshi billed for an impossibly high number of patients — 104, according to Neubauer’s recollection. Joshi said it was 81 Medicare patients, and 20 of them were seen by medical residents under his supervision.
Either way, Joshi was required to repay Medicare about $6,000 for the day of work. Joshi attributes the repayment to a coding error.
Joshi and El Salibi deny any wrongdoing. They said that if they wrote in the record that they saw the patient, then they saw the patient.
Having said that, El Salibi added that he doesn’t always have to see the patient to bill for services, because much of the work entails analyzing lab work.
A Medicare billing specialist said she could not imagine a situation in which infectious disease doctors would bill for hospital consultations without examining the patient.
• • •
Allegations about doctors fraudulently billing Medicare and insurance companies are whispered throughout the Las Vegas medical community, and for good reason.
Medicare, the federal government’s insurance for the disabled and those age 65 and over, spends more per patient in the Las Vegas region than in 90 percent of the regions nationwide, a recent study found. The high level of billing could suggest better care. But it is more likely, according to experts, that the government is paying for unnecessary services or ones that weren’t even rendered.
Donald White, spokesman for the U.S. Department of Health & Human Services’ Office of Inspector General, said Medicare fraud makes up the vast majority of fraud against the government and is so widespread it can’t be quantified. In 2008, the federal government recovered about $20.4 billion related to Medicare fraud, which made up about 83 percent of the total recoveries for all government programs, White said.
But how much more fraud occurred is unknown, he said.
Medicare is not the only target of medical billing fraud. The amount of bogus claims filed with private insurance companies is estimated to range between 3 percent and 10 percent of all billings, costing between $68 billion and $226 billion a year.
For all the suspicions of medical fraud, proving it is time consuming and difficult.
Investigations usually result in little more than a hand slap for the physicians. In November, six Las Vegas doctors — Dr. Robert Shreck, Dr. Tony Q.F. Chin, Dr. Craig M. Jorgenson, Dr. Wen Liang, Dr. Mohammed Najmi and Dr. Edmund Pasimio — several of them leaders in the medical community, paid $625,000 to Medicare after being accused of getting kickbacks for referring patients to a nurse practitioner, who performed unnecessary procedures. They were not required to admit any guilt in the settlement and continue to practice in the community.
And on Wednesday, Las Vegas radiologists Dr. William Boren and Dr. Luke Cesaretti agreed to pay $2 million to resolve allegations that they submitted false or fraudulent claims to Medicare. They did not have to admit any liability.
The 2004 Medicare audit of Joshi raises the question of how many patients an infectious disease specialist can reasonably care for in a single day.
Neubauer has no apparent reason to hold a grudge against Joshi, and Joshi says he is still friendly toward her. But she said she suspects that Joshi routinely billed for services he did not provide. She said when she balked at filing a high number of daily billings, he said, “Don’t worry about it, just do it.”
Joshi did not initially dispute Neubauer’s recollection that the Medicare audit revealed he had been paid for seeing 104 patients in a single day. He said the tally included the patients seen by him and El Salibi combined. When he was reminded that the audit occurred two years before El Salibi was hired, he then said the total was high because medical residents he was supervising at the time assisted him. That helped him go faster, he said.
Dr. Dean Milne, who supervises the residency program at Valley Hospital Medical Center, said it would actually take a doctor more time to supervise residents, because the process involves instructing the new doctors.
In a follow-up interview, Joshi then disputed the number altogether and said the audit showed that he had billed for 81 Medicare patients, and 20 of those were seen by residents.
Medicare officials would not comment on Joshi’s billing practices. The billings on that particular day were typical of what Joshi would send to Medicare, Neubauer said, and in addition he would bill patients with private health insurance.
Three infectious disease doctors told the Sun that seeing 30 patients in a day would require about 14 hours of intense labor. Joshi initially told the Sun he sees 30 to 35 patients a day but could see more than 40, because “some of the chronic patients might take a little bit less time.”
Neubauer said that Joshi never billed for fewer than 50 patients, seven days a week. And he often billed for 70 a day, she said.
• • •
Raye Kraft documented her case against Joshi and El Salibi in May 2007, when her husband was a patient at HealthSouth Tenaya.
• On May 4, 2007, El Salibi wrote in Kraft’s chart “patient is doing OK” and that the “PE” — shorthand for physical examination — was “unchanged.” Kraft wrote that El Salibi’s notes were an “outright fabrication” because “he never stepped foot” into her husband’s room. She wrote that she and her daughter were in the room from noon until 6 p.m. that day, and that El Salibi wrote his note at about 4:30 p.m. El Salibi did not write the time of his visit on his note, even though it is standard for doctors to do so.
• In his note four days later El Salibi indicated that Eugene Kraft’s condition was stable and that he checked his heart and abdomen. Raye Kraft wrote in her note that El Salibi did not visit the patient, which would clearly make it impossible to do a physical exam.
• Joshi’s notes from the May 9, 2007, consultation with Eugene Kraft are impossible to read — and that alone could be a violation of Nevada law, which requires doctors to maintain legible patient records. Raye Kraft’s notation on Joshi’s visit that day states that he stood at the doorway and waved, but performed no examination on her husband.
Eugene Kraft’s medical insurance was through the National Association of Letter Carriers Health Benefit Plan, which is run by the federal government. His medical bills show that the specialists billed all of their consultations — including many others where Raye Kraft noted they did not even enter his room — under the code “99232.”
The American Medical Association describes the code as appropriate for visits that include two of the three following components: an in-depth assessment of the problem and its history, an expanded problem-focused physical examination and decision making of moderate complexity. Physicians typically spend 25 minutes on a case to bill at the 99232 level, the AMA said. At that rate, a doctor would have to work around the clock to see 57 patients, and that would allow no time to travel between locations.
Dr. Dan McQuillen, a Boston specialist who is chairman of the Infectious Disease Society of America’s clinical affairs committee, said 25 minutes per visit is a good general guideline, but cases vary in their complexity. Sometimes it takes as few as 10 minutes to see a patient, and with new patients it might take an hour, he said.
Raye Kraft said she was angry that Eugene Kraft’s insurance paid the doctor’s bill. She said that in one case Eugene was “out of his head” on narcotic painkillers while El Salibi wrote in his chart that he had visited with the patient and he was “doing well and in good spirits.”
“He did not set foot in my husband’s room that day,” Kraft said. “My husband didn’t know if he was afoot or on horseback.”
Kraft said she complained to her insurance company, to the medical board and to officials at HealthSouth Tenaya. The hospital told her there had been complaints about the doctors, she said, but didn’t take any action. Nevada doctors can be difficult to police because while they have privileges at hospitals, generally they are not hospital employees.
The medical board told Kraft it is still investigating her complaint, she said. El Salibi and Joshi acknowledged the complaint, but insisted they never billed the patient for services they did not provide.
HealthSouth Tenaya CEO Timothy Deaton said officials investigated Kraft’s complaint, but the hospital does not deal with billing issues so its probe focused on whether the standard of care was met. The doctors had met the standard of care, the investigation concluded, and they still have privileges at the facility, Deaton said.
Her insurance company seemed to brush off her concerns.
“In a time of medical crisis for a patient many doctors are involved in the treatment,” the health benefit plan’s letter to Kraft said. “There are times when a patient may not remember the particular provider seeing them.”
Little did Kraft know that Phil Nevins had already filed his complaint with the medical board against Joshi and El Salibi.
Nevins sat by his wife’s bedside for weeks from September to November 2006 at HealthSouth Tenaya and was dissatisfied with the way the doctors seemed to be billing Medicare for services he claims they never provided.
Like Kraft, he decided to make a case and file a complaint against the doctors.
Nevins wrote down instances where the alleged fraud took place in the complaint he filed with the medical board in November 2006. According to medical board documents, the investigation took almost two years before being closed without action being taken against El Salibi and Joshi.
Nevins said he doesn’t think his wife, Phyllis, who is now deceased, was harmed by the lack of attention she received from El Salibi and Joshi because her chances of surviving were not good.
Still, he said, he was upset that the doctors billed Medicare for examinations they never performed.
“I think when they have a patient who has no hope they could care less — they milk you dry,” Nevins said.
Staff members at HealthSouth Tenaya said investigators from the medical board never interviewed them to determine whether the allegations by Kraft and Nevins contain merit. A health care worker from HealthSouth, who was afraid she’d lose her job if her name was published, told the Sun that she’s seen the same thing happen with hundreds of patients. El Salibi and Joshi, who do not work at the facility as much currently, would not even go into a patient’s room, the employee said.
“They’re not taking care of their patients and yet they’re billing Medicare for it,” she said.
El Salibi emphasized that it’s possible to look at lab and test results — and not the patient — to check the progress of an infection.
Lolita Jacobe, a billing expert for Medicare, said infectious disease specialists “have to see the patient face-to-face.”
Other infectious disease specialists agreed with Jacobe, saying that a physical exam, even if it’s just a quick look at a wound or a brief conversation with a patient, is necessary in every case.
“You don’t use labs to direct your therapy without getting input from the patient,” one of the infectious disease doctors said. “Ninety percent of knowing what’s happening to the patient is seeing him, talking to him, getting his feedback.”
McQuillen, who sets clinical policies for doctors nationally with the Infectious Disease Society of America, said it’s assumed that a doctor is always interacting face-to-face with a patient. The visit may be brief, and not everything needs to be documented to bill Medicare, but there always needs to be personal interaction, he said.
McQuillen does not know El Salibi, but he said that if his line of reasoning was taken to its logical conclusion, then a doctor could sign on to a patient’s electronic medical record from home, look at some labs and read some nursing notes, write his notes and then bill Medicare, he said.
“I don’t think that’s the way physicians in our society would advocate practicing medicine,” he said.
Joshi chalks the complaints up to professional jealousy. His practice, Infectious Disease Specialists, has grown in seven years, prompting other infectious disease specialists to conspire against him, he said. Joshi also blames El Salibi for the problems with the spouses of patients. In reference to the complaints coming from HealthSouth Tenaya, Joshi said: “El Salibi was the main guy who covered there.”
El Salibi, who now works on his own, blames Joshi for the complaints, saying his former boss pressured him to see so many patients in a day that he was running between facilities and unable to communicate properly with them. But he stresses that he never failed to provide quality care and never billed for services he did not provide.
El Salibi said Joshi easily manipulated him because Joshi sponsored his visa through a government program intended to bring foreign doctors to medically needy communities. El Salibi needed the job to stay in the country legally, so he never spoke out against Joshi — until now. He says he suffered in silence for almost three years, but will speak now because his immigration status is no longer dependent on Joshi.
Neubauer confirmed El Salibi’s account of being pressured to see patients by Joshi. She and El Salibi said that Joshi was driven by making money. Neubauer said that when she worked for him, Joshi billed up to $4 and $5 million annually.
“He said all the time, ‘I’m not making enough money. I need more money. I need more money,’ ” Neubauer recalled.
Joshi disagreed, saying he could not remember the particulars but that it was perhaps $2 million.
El Salibi and Neubauer said that Joshi threatened to fire El Salibi if he did not meet his daily quota of billings. El Salibi said the pressure to see so many patients resulted in a rushed bedside manner, but he never committed any kind of fraud.
“I have to clear my name,” El Salibi said. “I have to tell the truth. Why should I have to take the fall for him because of something that I didn’t do?”
Joshi laughed dismissively at El Salibi’s allegations of being overworked. He said El Salibi could have quit anytime he wanted and found another employer to sponsor his visa. The two of them worked up to 16 hours a day because they were doing a good job and their services were in demand, Joshi said. Plus, El Salibi was paid well, about $300,000 a year, he said.
“Nobody’s forcing anybody,” Joshi said.
Joshi said that in all the years that he has seen patients in Las Vegas — he’s been licensed since 1997 and estimated he sees 11,000 patients a year — only two complained to the medical board.
“If you look at the record there were no adverse outcomes for any patients,” Joshi said. “We didn’t treat anybody wrong.”
Pat Burns, spokesman for the national advocacy group Taxpayers Against Fraud, said that bill padding — doctors up-coding to make more money or charging for things they have not done — is rampant in health care. The cases are difficult to prove because of the complexity of providing medical care, the fear people have of blowing the whistle, and ignorance about where to go with their complaints. The government devotes few resources to recruiting whistleblowers or going on site to ferret out fraud, he said.
Fraud is the “logical choice” for unscrupulous doctors because the chance of getting caught is slight and the penalties for getting caught are weak, he said. The government just makes people repay what they stole, he said.
“The idea that this is a victimless crime is nonsense,” Burns said. “This is costing every family in America thousands of dollars a year.”