NEW ORLEANS – U.S. Attorney Duane A. Evans announced that SHIVA AKULA (“AKULA”), age 65, of New Orleans, Louisiana was charged by a grand jury on August 5, 2021, in a 23-count Indictment for Health Care Fraud.
AKULA owned and oversaw the day-to-day operations of Canon Healthcare, a hospice facility.
According to the Indictment, AKULA unlawfully enriched himself by submitting and causing the submission of false and fraudulent claims to health care benefit programs, including Medicare. AKULA instructed Canon employees to improperly bill for General Inpatient (“GIP”) services to maximize reimbursement from health care benefit programs, knowing that those services were not medically necessary.
Canon routinely billed physician services with Common Procedural Terminology (“CPT”) Code 99233 for beneficiaries who were receiving GIP services, in addition to the daily per diem rate. CPT Code 99233 is an evaluation and management code, which requires two of the three following components: (1) detailed interval history; (2) detailed examination; or (3) medical decision making of a high complexity. Usually, the beneficiary is unstable or has developed a significant complication or a significant new problem.
Canon routinely billed for physician services for CPT Code 99236 for beneficiaries who were admitted into GIP and remained on GIP for more than 24 hours. CPT Code 99236 should only be billed when a patient is admitted to inpatient hospital care for a minimum of 8 hours, but less than 24 hours and discharged on the same calendar day. In addition, when billing for CPT Code 99236, the physician shall identify that he or she was physically present and that he or she performed the initial hospital care service. The physician shall personally document the admission and discharge notes and include the number of hours the beneficiary remained in inpatient hospital status.
From on or about January 1, 2013, to on or about August 25, 2017, Canon submitted approximately 1,053 claims for CPT code 99236 and was paid approximately $223,601 by Medicare. During that same time period, Canon submitted approximately $2,281,251. These physician services reflected in CPT Codes 99236 and 99233 should not have been billed as a separate line item in addition to the GIP services because they were included within the daily per diem rate that Medicare paid for the GIP services.
From on or about January 1, 2013, through on or about August 25, 2017, Canon submitted claims to Medicare for approximately 1,949 home visits using CPT code 99350 that were purported to have been performed by a doctor, when a doctor did not perform home visits. As a result of these 1,949 home visits, Medicare reimbursed Canon approximated $316,384.
From January 2013 to December 2019, Canon billed Medicare approximately $62,833,346.28 and was paid approximately $47,106,838.94.
If convicted, AKULA faces a maximum of 10 years imprisonment, a fine of not more than $250,000, supervised release of up to 3 years, and a mandatory special assessment of $100 as to each count.
U.S. Attorney Evans reiterated that the Indictment is merely a charge and that the guilt of the defendant must be proven beyond a reasonable doubt.
The case was investigated by the Federal Bureau of Investigation, the Department of Health and Human Services Office of Inspector General, and the Louisiana Department of Justice, Medicaid Fraud Control Unit. The case is being prosecuted by Assistant U.S. Attorney Kathryn McHugh.
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