Newton Doctor Accused Of Fraud To Pay $680K In Settlement

NEWTON, MA – A Newton doctor has agreed to pay $680,000 to resolve allegations that he violated the False Claims Act by submitting inflated claims to Medicare and the Massachusetts Medicaid program (MassHealth) for care to nursing home patients, the US Attorney's Office and the Attorney General announced Thursday.

“This doctor stole hundreds of thousands of dollars from MassHealth – taking away health care resources for those who are most in need,” said Attorney General Maura Healey in a statement. “We will continue to take action to defend the integrity of MassHealth and protect Massachusetts residents.”

Hooshang Poor, who has been treating patients in long-term care facilities since 1987, was audited by MassHealth and the state in 2017. The government contends that, between June 1, 2011 and May 31, 2017, Poor submitted inflated claims for nursing home care by assigning false procedural codes that overstated the length, extent, and scope of services he and his employees furnished to nursing home residents, according to the government in the settlement agreement.

“Dr. Poor enriched himself at taxpayer expense by improperly billing Medicare and Medicaid,” said United States Attorney Andrew E. Lelling in a statement.

Poor did not abide by MassHealth limitations on the frequency of billable visits and did not use required modifier codes when billing for care his non-physician employees provided, causing MassHealth to reimburse inflated amounts for those services, according to a government audit in 2017.

Under MassHealth regulations, physicians can only bill MassHealth for one evaluation and management claim per member per month for patients in long-term-care facilities, unless there is a documented medical emergency. However, the audit found that Poor submitted claims in excess of what these regulations allow in 2,272 instances that were not predicated on medical emergencies. The audit found that in one instance, Poor billed MassHealth for 10 evaluation and management services to one member in a month.

The audit also found that Poor billed MassHealth for more than $15,000 in services that took place while he was traveling abroad on 10 different occasions.

The audit found Poor used improper billing and modifier codes, and lacked documentation to support his claims, resulting in additional improper payments.

The government said Poor did not establish proper guidelines for his staff to follow when prescribing medications to their patients and yet during the audit period, Poor’s nurse practitioner and physician’s assistant wrote 657 prescriptions, including 211 for narcotics such as fentanyl, oxycodone, and methadone.

Poor told auditors he wasn't familiar with the rules in some cases and claimed he had made errors in other cases according to the auditor's report:

"If there is concern that patients were being seen more than clinically appropriate, then I would like to review these specific cases with a clinical adviser and clarify the management. Specifically, I would like to know which patients they believe I should have ignored, or whose care I should have postponed to another month. . . . And please be advised that you will not be able to enforce me to check the patient’s ability to pay or type of her/his insurance before visit to avoid visiting more than once a month," he said according to the audit.

Under the terms of the agreement with the United States and the Commonwealth of Massachusetts, Dr. Poor will pay $265,896 to the Medicare program and $414,103 to the Medicaid program.

Poor has also agreed to be subject to a comprehensive compliance program implemented and overseen by an independent compliance monitor. This program will require Poor to update policies, procedures, and employee trainings to address his coding and billing practices, and will further require annual on-site audits of Poor’s compliance with state and federal laws for the next three years.

“It’s our agency’s mission to ensure government health funds are spent properly,” said Special Agent in Charge Phillip Coyne of the U.S. Department of Health and Human Services Office of Inspector General. “Working with our Federal and State partners, we will continue to hold accountable any medical professional who bills Medicare and Medicaid for more intensive and expensive services than those actually provided."

READ the state's Audit of Poor.

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