Former employee testifies to billing practices in healthcare fraud case

A former employee for Dr. Jorge Zamora Quezada, the rheumatologist on trial for alleged healthcare fraud, testified Friday of unusual instructions she received as the billing supervisor for the doctor’s clinic.

Graciela Salinas, a certified medical coder, was called up to testify as a witness for the government which is being represented by Adrienne Ellen Frazior.

Salinas said she worked at the Center for Arthritis and Osteoporosis, Zamora Quezada’s clinic in Edinburg, for about two years between January 2004 and December 2005.

As the former billing supervisor, she testified about a document in their office that listed all the procedures they had to bill for each patient. The document had three columns: procedures to be billed for each patient on their first visit, procedures to be billed for their second visit, and procedures to be billed for all patients on their third visit.

Salinas testified about her interactions with the doctor and his weekly meetings with the supervisors of all the departments during which he would urge her department to work getting their billing up to date. There was a large backlog in their billing when she came on board, Salinas said, which had been somewhat reduced by the time she left.

Zamora Quezada is accused of committing healthcare fraud by misdiagnosing and over-treating patients in order to defraud health insurers.

His wife, Meisy Zamora, is also accused of participating in the scheme — which allegedly involved tampering with medical records and money laundering — along with two of their employees: Felix Ramos and Estella Santos Natera.

Salinas testified that she didn’t have much interaction with Meisy Zamora as she wasn’t around in the office during Salinas’ first year there. During her second year of work, however, she said Zamora did participate in the weekly meetings and that she was told to refer to her as “Doctora Meisy.”

While she did not know Santos Natera, Salinas said Ramos was sometimes present at those meetings and described him as Zamora Quezada’s “right hand.”

She said communication with the doctor usually happened through him and that whatever the doctor needed, Ramos would do.

Her departure, she said, was prompted by a meeting with Zamora Quezada during which he allegedly told her that the charges for the other doctor who worked in the clinic were low and should be billing for the same things that he was.

After that conversation, Salinas said she submitted her two weeks’ notice.

Earlier in the day, the jury heard from Patricia Escoe, the divisional vice president for plan performance for Blue Cross and Blue Shield of Texas, the insurance provider which previously had Zamora Quezada as one of their in-network doctors.

Escoe testified that Zamora became a network provider in 2003 but was terminated in 2006 based off his utilization data.

She explained that a peer group — or committee — determined that the frequency with which diagnostic procedures were ordered appeared to be out of step from other doctors.

Zamora Quezada appealed the decision by providing documentation to support his procedures to the committee but they determined his utilization of procedures was not supported by the information provided and stood by their decision.

Two years later, however, Zamora Quezada was permitted back into the network.

When she was questioned on cross examination by Stephen Lee, one of the attorneys for Zamora Quezada, she said Blue Cross, Blue Shield could have terminated him if they believed there was threat of imminent harm to patients or if they thought he had committed fraud.

She also said they could have placed the doctor on pre-payment review if there were concerns about him but Lee noted that they did none of those things.

When they terminated him in 2018, Lee stressed, it was after his arrest and solely based off the government’s allegations.

On re-direct questioning by the government, though, she testified that if a provider had altered medical records, that could hinder their ability to detect fraud in the first place.

Escoe was also asked about claims data submitted to Blue Cross and agreed that, at least according to one worksheet of data, only 36 percent of the services billed were associated with rheumatoid arthritis and that less than half of what Blue Cross paid — $2.532 million out of $7.339 million — was for rheumatoid arthritis.

Upon questioning from Jaime Peña, the attorney for Felix Ramos, she agreed it would be incorrect to say that everyone who was diagnosed with rheumatoid arthritis was ordered an MRI or bone density scan.

Friday’s testimony concluded with Dr. Naiara Alvarez, a Harlingen-based rheumatologist who began testifying on Thursday about her experience with two of Zamora Quezada’s former patients.

During Friday’s testimony, Lee went over the medical records of those two patients and asked her about the moral obligations of doctors to report other doctors they think may have acted fraudulently.

She acknowledged they do have that moral obligation and Lee noted that she didn’t report Zamora Quezada to the Texas Medical Board, to Medicaid or Medicare, or to Blue Cross.

She said that if she had suspected fraud, she would have reported him.

When Peña questioned her, he sought to clarify the use of methotrexate by rheumatologists which was referred to as a chemotherapy drug in the government’s indictment.

Alvarez said the drug had multiple uses but was not used as a chemotherapy drug in their field.

She acknowledged that the drug was the “first line of defense” for rheumatoid arthritis and that she also used it in her practice.

In response to a question from Peña, she said she could be accused of prescribing chemotherapy drugs but that that would be false.

Upon re-direct from the government, Alvarez added that she would not give methotrexate to someone who did not have a type of inflammatory arthritis such as rheumatoid arthritis.

Frazior, the attorney for the government, also asked if she would order the same set of procedures for every patient’s first visit, another set of procedures for every patient’s second visit, and another set of procedures for every patient’s third visit like Salinas alleged was the practice for Zamora’s clinic.

Alvarez replied that she would not.

Soon after, Alvarez was dismissed from the witness stand and the court broke for the day.

Testimony in the trial is scheduled to continue Monday morning.