Newport Radiologist Faces Nearly 900 Counts of Felony Insurance Fraud
Authorities say Dr. Sim Carlisle Hoffman ran a scheme that overbilled workers' compensation insurance for $17 million.
A grand jury indictment unsealed Monday accuses a Newport Beach radiologist and three others who worked for him in a Buena Park medical office, including a neurologist, with a $17 million workers' compensation insurance fraud scheme.
Dr. Sim Carlisle Hoffman, 59, of Newport Beach, Dr. Thomas Michael Heric, 74, of Malibu, Beverly Jane Mitchell, 60, of Westlake Village, and Louis Umberto Santillan, 44, of Chino Hills are accused of overbilling for unnecessary or never-performed procedures, said Orange County District Attorney Tony Rackauckas.
Hoffman, a radiologist who owns Advanced Professional Imaging, Advanced Management Services and Better Sleeping Medical Center in Buena Park, faces 883 counts of insurance fraud and one count of aiding and abetting the unauthorized practice of medicine -- all felonies.
Mitchell, the administrator in charge of insurance billing for Hoffman's businesses, faces the same charges as Hoffman. Heric, a neurologist, worked for Hoffman at the Better Sleeping Medical Center. He is charged with 296 counts of insurance fraud and one count of aiding and abetting the unauthorized practice of medicine.
Santillan, who did billing collections for Advanced Professional Imaging, is charged with 141 felony counts of insurance fraud. "The mastermind of this medical mill is Dr. Sim Hoffman," Rackauckas alleged. "Hoffman is a radiologist who owns the sleep and nerve testing centers. He is charged for using patients as props in order to bilk the system by overbilling the insurance companies"' he said.
"Dr. Hoffman was disciplined in 2001 by the Medical Board of California for similar unethical medical practices." Hoffman had Heric "study'' patients and write reports on their status, Rackauckas said. "Heric's so-called `studying' of patients involved using a made-up formula entirely of his own creation that is not recognized in any medical community,'' Rackauckas said.
The reports were of a "cookie-cutter'' variety, and none of the patients were given any treatment for their disabilities, the county's top prosecutor said. Heric's license was suspended for 60 days in 2008 for a felony
Medicare and Medi-Cal fraud conviction, Rackauckas said. Hoffman hired Mitchell after he was disciplined in 2001, Rackauckas said. Santillan, who has no college degree or certification, is accused of collecting more than $800,000 in commissions from fraudulently received insurance payments over two years, Rackauckas said. At the nerve-testing center, patients underwent painful testing that cost $330 instead of a much-less invasive exam that cost $35, Rackauckas alleged. Only two doctors in California are qualified to perform the more expensive and invasive test, he added.
"Hoffman is not one of those two doctors,'' the prosecutor said, ``and Hoffman didn't just bill for one Single Fiber EMG per patient. According to his bills, the patients went through this painful procedure over 20 times each."
A 56-year-old woman who hurt her wrist and ankle when she tripped over some boxes at work was referred to Hoffman, who had her undergo a sleep study, MRI and nerve testing, Rackauckas said. The woman "was never told the results of her diagnostic tests,'' Rackauckas said. "Months later, she was informed by her attorney that her claim had been denied by the insurance company."
Hoffman has still pursued payment from the unidentified woman through liens amounting to more than $15,000, Rackauckas said. "These patients were used as pawns in Hoffman's piggy bank," Rackauckas alleged. The four "created a $17 million medical mill at the expense of over 1,200 patients and the workers' compensation insurance system," Rackauckas charged.
State Insurance Commissioner Dave Jones said such fraud drives up insurance premiums for legitimate businesses. Zenith Insurance Co. brought the alleged fraud to light with a complaint to the insurance commissioner's office in July 2008, Jones said.
"It's outrageous, and the prosecution announced today will send a clear signal to medical providers,'' Jones said. "We're taking it seriously as we should because it's a drag on our economy.'' The four were indicted May 11, but the grand jury indictments were not unsealed until Monday.
— Paul Anderson/City News Service
Upset By Injustice
5:42 pm on Thursday, June 30, 2011
This appears to me to be a setup by 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”or suffer the consequences.
Since when do diagnostic studies provide medical care? That's like asking a radiologist to set a broken bone seen on an x-ray taken at their facility. In the article's example of the poor woman who it is claimed that she didn't get the medical help she desperately needed, it was Zenith Insurance who denied her claim and shamelessly left her with no recourse! How many times do you hear about bohemith, money hungry insurance companies denying legitimate claims, leaving innocent victims untreated and fending for themselves and in the poor house?
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 the ascertion that Zenith provides approximately 30% of the budget for the OC District Attorney’s Office? If true, it 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!
Political Watchdog
5:30 pm on Tuesday, July 5, 2011
omments about insurance companies and political donations are very interesting indeed! Will Zenith make available the corporate jet to Tony Rackauckas as was purportedly done with Gil Garcetti? Or will another $150,000,000.00 do the job? Insuranced funded individuals with political ambitions may result in misguided indictments and a big waste of public resources! If this is the case, shame on all of them!