The former chief executive officer of Texas-based Palo Pinto General Hospital has pleaded guilty to defrauding three major insurance providers – BlueCross BlueShield of Texas, CIGNA Texas, and United Healthcare – out of millions of dollars.
According to his plea papers, the hospital's chief executive officer, Harris Brooks used the hospital's in-network contracts with large health insurance companies to engage in pass-through billing for laboratory services from September 2017 through June 2018.
Prosecutors asserted that, using the hospital's national provider identification number, Brooks submitted claims to insurance companies for allergy and genetic testing purportedly performed at the hospital.
In reality, however, the hospital did not have the equipment on-site to perform the tests for which it submitted claims, and the patients for whom claims were submitted were receiving treatment at various spas and clinics throughout Texas and elsewhere, not at Palo Pinto. The patients did not know about the pass-through charges using the hospital's insurance contracts, the government said.
Over the nine-month period, the government asserted, Brooks submitted claims to health insurance providers for laboratory services totaling more than $55 million, the vast majority of which were fraudulent. As a result of these claims, the insurance companies paid the hospital more than $9 million.
The purpose of the scheme was to receive higher rates of reimbursement from the insurance companies, the government said.
According to his plea agreement, Brooks faces up to five years in prison and will be required to pay restitution to those he defrauded.
Steven A. Meyerowitz
Steven A. Meyerowitz, a Harvard Law School graduate, is the founder and president of Meyerowitz Communications Inc., a law firm marketing communications consulting company. He may be contacted at [email protected].